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Rachel Handley for BABCP
Let's Talk about CBT- Practice Matters
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  • Befriending the naughty black dog…. Prof Barney Dunn on learning to live well alongside depression
    In this episode, Rachel talks with Professor Barney Dunn, clinical psychologist and researcher at the University of Exeter, about his work on Augmented Depression Therapy (ADepT) a novel approach to treating depression that targets anhedonia (difficulty experiencing pleasure) and aims to boost wellbeing. Barney shares personal and professional insights into why and how traditional CBT might be augmented to actively help people rediscover joy and meaning in life. He explains how ADepT, based on systematic research, integrates cognitive behavioural principles with techniques from ACT, mindfulness, strengths-based CBT and more, all aimed at helping clients live well alongside depression rather than simply reduce symptoms. Whether you’re a therapist working with depression or simply curious about new directions in CBT, this episode offers a thought-provoking and inspiring conversation about what it really means to get better- and stay better. Resources & Further Learning: Find more information about Barney and his publications here Find out more about ADepT here Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [email protected] Subscribe and leave a review – and don’t forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, we're joined by Barney Dunn, a highly renowned research and clinical psychologist specialising in therapies to improve wellbeing and functioning in depression and related mental health conditions. Professor Dunn is based at the University of Exeter, and he has a finger in many interesting pies, but today he's here to talk particularly about his work developing and implementing treatment for depression with a particular focus on symptoms of anhedonia. Thanks so much for joining us, Barney. Barney: Thank you very much for having me, delighted to be here. Rachel: And just as a starter, we want to think about how you got into this area of research. And as I said, you're interested in lots of different things, but you've devoted a lot of your time and effort to thinking about anhedonia. There's so much to fascinate in clinical psychology. I wonder what got you interested in the field of depression and specifically this anhedonia area personally and professionally? Barney: Professionally, when I was doing clinical training and learning to cut my teeth with a lot of depression cases, hitting a point where I felt like I'd done quite a lot of work reducing the negative and reducing symptoms, but the job was only half done. And clients were saying things like, at the end of therapy, well, I'm not depressed anymore, but I'm still not quite sure what life's for and I'm not enjoying stuff. And I felt...Well, maybe I'm not doing CBT correctly, or maybe there's a bit of a trick missing about how we can do that stuff better. So that was the kind of professional route into it. The personal route into it was a bit more growing up with my dad. So I lost my mum when I was little and was very well supported by my family but seeing my dad in my eyes never quite get back to life, never rediscovering joy and connection and meaning and grinding through and turning the wheels, but not getting pleasure back and thinking there's a missed opportunity there. Even after the difficult, there's possibility for the good. And so that's the kind of personal motivation is thinking of clients like my dad, how could I help them get back to life when they've been through some difficulty and rediscover wellbeing and joy? Rachel So that really meaningful connection for you from your own lived experience with being alongside someone who never got that meaning back. Those are big questions. And I hear what you say, you working in depression, you get good results with your clients in terms of their symptoms improving, but you talked about a job half well done or half done. Currently, how well are these symptoms targeted in mainstream treatments? I mean, it's a brave man who takes on, you know, Beckian cognitive therapy and thinks, right, we need to do better. Barney: Well, I mean, we should follow the data. So if you do Beckian cognitive therapy and indeed any other evidence-based treatment for depression under ideal circumstances, really good therapists who are really well supervised, you basically get about 60 % of clients who will meet diagnostic remission at the end, half of whom will relapse within the next two years. So that's ultimately a 30 % proper response rate. And that means we leave a lot of people with a lot of distress afterwards, you know, 70 % of the people that are coming through our doors. If you look at NHS Talking Therapies reliable recovery rates for depression lag a bit behind anxiety recovery rates, and they're a bit below 40%. So more than 60 % of the folks coming through NHS Talking Therapies with depression will be depressed again within a couple of years. So there's definitely still a problem to solve and it feels like a really interesting and clinically important question to work on but one to be humble about because lots of really great minds and really hardworking people have thrown themselves at it, and what we've done is proliferated a lot of equally partially effective treatments but we haven't made any stepwise gains since Beck who did make that massive stepwise improvement in the late 70s. Rachel: Yeah. So it's great that there's evidence-based treatments are out there, but there's still a lot of people that find that there's something lacking at the end of therapy or even don't improve. So if we treat the sort of negative feelings, so there's negative symptoms of depression. Doesn't that automatically also address some of this anhedonia or positive valence system? And if not, why not? Barney:  So I think that's the assumption we all came from to start with, which is there's a continuum of affects, which you go from being really negative, you get to this middle point where you've been meh, and then you move to this position where you're feeling really positive. So if you bring down the negative, the positive will inevitably increase. But then there's been some interesting other ways of thinking about that and recognising that they're at least partially dissociable systems, which means positive affect can move when negative affect doesn't move and vice versa. And again, just to come back to my dad as a case example, when my dad was dying of cancer, there was a lot of distress and difficulty and pain. And there wasn't a way to make that go away. He was dying of cancer, but that didn't mean there weren't things we could do to find wellbeing within the midst of that. One of my favourite memories with my dad in the last few months was he wanted to drive his car again, but he was on too much morphine to drive safely. So we put him on the sit on mower and drove around the garden, kind of destroying my mum's prized flower beds and my stepmother's prized flower beds. And that's one of my favourite memories, like chuckling with my dad on morphine, driving badly around the garden, amongst a whole lot of negative affect. So I think it's quite useful to realise even in the midst of depression, you can find joy and pleasure. There's also an increasing basic science argument here, which is the systems of the mind and brain that regulate negative emotions and avoidance of threat are partially dissociable from the systems of mind and brain that regulate positive emotions and approach towards things. So you can move one without moving the other. And my view is you need to do both in therapy. Bring down the negative, push up the positive. Rachel: Does everyone experience, I mean, you've just spoken about an example of your dad experiencing lots of negative emotion, but still having that positive emotion. Does anhedonia develop for some people and not others in the context of depression? Barney: I think it's like most ways of thinking about depression, things fall on a continuum. Estimates of how many clients have clinically significant anhedonia ranges from 30 % of them having really severe and profound anhedonia to 70 % having significant anhedonia. It's one of the, along with elevated negative affect, it's one of the two cardinal symptoms you need to get a diagnosis of depression. So it's pretty prevalent, but it isn't there for everyone. And it isn't there for the people that have it all of the time. Its just sometimes people need to develop the skillset when anhedonia is with me, how can I step away from it and get back to wellbeing and joy? Rachel: And is there a differential pathway? I mean, will it be some people who are more likely to develop anhedonia than others or circumstances that are likely to lead to that? Or as you say, is it just likely to be there or not at different times than that pathway? Barney: Well, so my view again is like most symptoms, there are many ways into it and many ways out of it. So it's dangerous to put hard and fast generalisations onto it. But I would say there definitely is a kind of genetic, biological basis for your reward system to be more or less reactive for better or for worse. So some people are just born with a capacity that reward washes over them and they really enjoy it. Others have to work a bit harder. I'm increasingly struck that in people's developmental histories, an absence of early positive experiences then makes it hard to understand and be able to lean into positive emotions. I love the move towards trauma-informed practice, but I think we also need to have just as much focus on clients who've missed the positive and how we can grow that system later from scratch when it wasn't developed during childhood. There is also a pathway from chronic exposure and stress and trauma that alters the reward system. So I'd say there are those three groups of biological predisposition to anhedonia, people through complex trauma have kind of what we'd call neuroendocrine scarring, the kind of hormonal and biological systems that regulate, change the positive affect system, and then people who just weren't exposed to reward and didn't learn how to play with it when they growing up. Rachel: And this for many people is kind of quite a new language and a new way of thinking. Lots of people listening to this podcast will have started their training in CBT, either as CBT therapists or within other professional trainings with the Beckian model of depression and learning their skills. And if we say the words, core beliefs or dysfunctional assumptions, they'll already be mapping out in their minds a longitudinal maintenance formulation. What would a formulation of depression look like taking into account these systems of positive effect and reward processing these kinds of perspectives? And before you start Barney, I need to make you aware of our Practice Matters podcast challenge. So we like a good formulation, but there can be no boxes or arrows or other visual aids because we're an audio podcast. So just a brief explanation about how the problem develops and is maintained without repetition, hesitation, deviation, power point, whiteboards or flip charts. Barney: I like the challenge, Rachel, and you also know me, I'll ignore the rules as we go along slightly. So I'm to give you a narrow formulation of what might get in the way of a client enjoying potentially rewarding experiences. In the therapy ADepT. we've developed, we think about psychological mechanisms of mind that when people are exposed to potential opportunities, get in the way of that leading to sustained and ongoing positive emotions. The first thing is behaviour avoidance, people don't put themselves in situations that are potentially rewarding. The second thing is behavioural shaping. So they're not choosing activities and refining activities in the best way they have to land. So if I'm going to a party, arriving with friends and making sure the music I like is playing. The third one is intentional. When they're in a potentially rewarding situation, they're noticing the bits they don't like rather than the bits they do like. So maybe I'm out for a beautiful meal but don't like peas, so I focus excessively on the peas on my plate, not the beautiful prawns I really like. Rachel: My kids need this. I'm just saying. Barney: The fourth one's kind of cognitive. So what we're realising is a lot of clients who are depressed have a set of appraisals when positive emotions start to switch on that dampen them or crush them. It's because they're a bit alien and scary and weird and uncomfortable. And the appraisals are things like, this is too good to last, I don't deserve this, people will think I'm too big to my boots. So what those kind of appraisals do is they instantly extinguish the positive emotion. And it's a bit like a candle snuffer in a church. The flame is instantly squashed. And what you're left with is the smouldering flame that isn't very pleasant afterwards. There's also a nature of how experientially engaged in the positive activity people are. Are they being very heady and evaluative? A bit like Barney going to a party and wall flowering at the edge and not really being part of it, watching it, versus Barney going to a party and really connecting to the sensory experience. So in ADepT, what we're doing is we're spotting all of those patterns that get in the way of positive affect, triggering and sustaining, and we're getting clients to take a step in the opposite direction. So when they want to avoid, we get them to approach. When they're focusing on the negative, we give them skills to focus on the positive. When we're having dampening appraisals, we give them skills to come up with realistic positive appraisals that can help them engage. When they're being very stuck in the head, how can we get them back into the mindful everyday moment and so on. Rachel: So that was a brilliant summary, Barney. And I know you've talked about high ADepT. You like to keep things short and punchy. So you're obviously well practiced at that. But you've said that there's key factors of behavioural avoidance, behavioural shaping, attentional processes and cognitive processes that are maintaining the model. And you've talked already a little bit about how your treatment focuses on that. Can you tell us a little bit about ADepT? What ADepT stands for and what that means. Barney: Well, so ADepT stands for Augmented Depression Therapy, which was basically an attempt to get better at treating anhedonia in depression. And the broad formulation model in ADepT goes something like this. We think people get depressed for good reason, usually because life isn't going in the way that they'd want it to. So what we're trying to do is help clients clarify what's important to them and makes them tick. So that's values work. Then we try and behaviourally activate them towards getting more of that stuff in their lives. And we fully expect that when that happens, depression is going to try and trip them up as they go. Life will throw them challenges and depression finds ways to make those small hills turn into mountains. How can we take a step away where clients have resilience to challenges in life? Life also simultaneously throws us opportunities and depression is really good at snuffing those out, how can we help clients instead lean into those opportunities? So we're trying to create a virtuous circle where clients clarify and move towards what's important to them and act opposite to their depression so that they get the full potential out of these life situations they're engaging in. And I guess the flip from CBT is actually producing depression isn't the goal here. By the time most people are coming to see us, certainly for high intensity CBT, they're usually on their third or fourth or fifth or sixth episode, if you look at the epidemiology of depression, we know it is a kindling condition that people are likely to have an ongoing vulnerability for. And in some ways it's an unrealistically optimistic model to say, I can cure you, I can get rid of this thing. In ADepT, we're instead saying, how can we support you to live well alongside your depression so that you can have wellbeing? And by wellbeing, we mean getting meaning, getting pleasure, getting social connection. And we frame depression as a barrier to achieving those goals. And we say to people, there'll be times in life when you are in a depressed episode, how can we help you get as much wellbeing at those times as you can? There'll also be times when you're not in a depressed episode, how can we really help you lean into wellbeing at those times? So it's ultimately learning to live well alongside depression, befriending the naughty black dog that's tripping you up and trying to turn it into a bit more of friendly house pet that you trust in your living room. Rachel:  And I was struck by what you said at the top of the podcast around, you know, patients getting to the end of treatment for depression and maybe feeling less low, but saying, actually, this hasn't addressed this huge important aspect to me of where's the meaning in my life and where's the positivity at the front end of treatment when you're engaging them in this idea of, of not maybe targeting the depression or, or the goal not being to be depression free but rather one of wellbeing. How do folk engage with that? Barney: I mean, this was one of the really interesting empirical questions when we talk, because I guess the standard view was you can do this well-being work at the end once you've got people better. And surely it will be profoundly invalidating to say to people right at the start of the work, let's really think about what will make you tick and make you want to get out of bed. And what we've found is the opposite. If you clarify what's important to people and help them move towards it, it often helps give them the motivation to keep pushing through when their depression is saying, all I want to do is lie in bed, stay on the sofa and withdraw. Having that, this is what my mind is telling me now, but what's important to me at a higher order level is I want to be a good father or maybe I want to be a marathon runner or maybe I want to do a good job at work. That can give me enough distal motivation to keep me pushing through the avoidance. Rachel: It sounds like as in standard cognitive therapy with depression, would expect trip ups, we would expect ups and downs and we might often formulate those in therapy as an opportunity to test things out. It sounds like those are not only formulated as an opportunity to test things out or put strategies into practice, but actually almost quite essential to the ADepT process that people are experiencing those trip ups to be able to kind of implement what they're learning. Barney:  Yeah, one of the things I found in my early CBT practice was I was thinking, well, these people are struggling to get back to reward. So thinking all I've got to do is give them a massive hit of reward. So they used to like parties, let's throw the best party ever so they can get back there. And people were trying it, and they were finding it really quite aversive and saying, I don't like that anymore. And then I was at a kind of talk by Paul Salkovskis, he was being really entertainingly provocative about how badly we've done in the depression field. They say you depression folk just need to learn from the anxiety folk about how to improve CBT outcomes. So I thought okay, I'm going to do a thought experiment of taking it literally. What happens if we re-conceptualise anhedonia as an anxiety disorder where the phobic stimulus is a fear of the good. What would I do there? Well, I'll do a graded exposure hierarchy where I'd gradually get people back towards rewarding activity in small steps. I'd fully anticipate it's going to be difficult as they re-engage with this stuff. They need to stay in it long enough for the difficulty to pass so that something new can come out at the end. And I'm going to keep really vigilant for safety behaviours that get in the way. So all of those psychological mechanisms I talked about earlier that get in the way of pleasure experience, you can conceptualize them as safety behaviours. We're trying to encourage clients to drop them, take a step in the opposite direction, sit with the initial discomfort of feeling positive. It feels unsafe, it feels weird, it can feel a bit disgusting for some clients who haven't had it for a while. Trust if you stay there long enough, the light starts to come in and feel a bit different. So that's the flip from how I used to do classic CBT behavioural activation. And we're really explicit in that early behavioural activation. What we're trying to understand here is how your depression trips you up. We're not expecting you to enjoy this stuff initially. What we want to understand is how's that depression coming in and snuffing that candle out so it gets blown out instantly. And we just welcome that as an opportunity. Great. We're now understanding how your depression trips you up as there's the chance to do something different with it. Rachel: So the major thrust of the therapy in all of this is that this thrust towards wellbeing and value and along the way there's going to be ups and downs. But actually those are to be expected and utilised in terms of developing those skills. Barney: And there will definitely be downs, but there are always ups, even with the most depressed clients. Because where, I'm sure we've all had this, where your depressed client comes in through and say, how's your week been? And they go, nothing's happened. And then you look at their mood diary, and there is always some variability in it. Now as a CBT therapist, I'm really well trained to say great, there's that really difficult, challenging point where they had an argument or they wanted to self-harm or their mood really dropped. And my attention would naturally be drawn there to go, let's understand and formulate and give them a way to step out of it. But what's it like if you do the thought experiment of let's look at those moments where it wasn't that, where it was slightly less low or maybe even good, what was happening there? Can you put an equal amount of your attention or focus on that? So clients learn from the good. And certainly, my experience when working with classic CBT is when negative affect is flooding the room and stuff is feeling really difficult, that's when our minds are really not open to cognitive change. It's like new ideas bounce off people, they're resistant. I found it much easier to actually do the cognitive work with people after a positive exception. So you're looking for those moments where it's been a bit different. You're reactivating them in the room so that positive emotion is switched on a little bit. And we know the evolutionary function of positive emotion is it makes us a bit more creative. It makes us a bit more open to social connection, and it makes us a bit more open to activation. So that's the time when it's easier to do the cognitive work after a positive exception, not in the midst of a negative pattern. So we're doing the cognitive change work in a different place. Rachel:  And being creative, social and activated sounds like a good place to be. And you've said that ADepT integrates interventions from CBT, ACT, positive CBT, strengths-based CBT, wellbeing therapy, goal setting and planning approaches, behavioural activation, MBCT, future directed therapy, the cognitive behavioural analysis system of psychotherapy and dialectical behavioural therapy, and that it integrates ideas from positive psychology literature. That's a huge and diverse range of approaches. What unifies the approach and makes it not just a sort of bunch of eclectic techniques, because I know that's not the way you work Barney. Barney: So I sometimes see two traditions of CBT. There's the very, I'd call the UK tradition is a very manualised one where we need to do it in exactly the way trials have shown it works that of following this particular treatment and anything off that is unhelpful therapeutic drift. But actually we need to remember the Beckian origins. Tim Beck was the ultimate theoretical magpie. And the few times I was lucky enough to meet him, he was really clear. It's good CBT if the intervention elements you are choosing match your cognitive case conceptualisation. So in ADepT terms, I'm thinking, what is the valued activity someone's working towards? What's the depressive mechanism of mind that's getting in the way of them dealing with the challenge or taking the opportunity? And therefore, what is the intervention element I want to bring in now that will help them step away from that So if a client is riddled with self-criticism and I want to move them towards self-compassion, I think about how can I weave in some ideas about compassion focused therapy, but in ADepT language where we're doing it with solution focused stuff. If a client's very behaviour avoidant, I'd go back to behavioural activation routes and I would think, okay, what are the ways to activate clients here, break things down into small steps, think about SMART goals and whatever, but I'm doing it in solution focused language. So what orients ADepT as a cohesive therapy is activating people towards values, spotting mechanisms of mind that trip people up and choosing an intervention element that has an evidence base to work on that mechanism. Rachel: And those mechanisms have been identified through basic science and cognitive science and theories and testing. Barney: Yeah, and actually, this is me putting a bit of provocative challenge back to the conventional CBT depression crowd. If you actually look at how highly established has been the mechanism for negative Beckian cognitive therapy, it's a little bit mixed. In my world, if something's really going to be a mechanism you should target in therapy, you need to have quite a high evidential bar that you should be working with it. It should be associated with the phenomena of interest and the mechanism should correlate with anhedonia prospectively and longitudinally. When you manipulate it in the lab, so you turn a mechanism on or off, anhedonia should come up or it should come down. When you do a treatment trial, the extent to which you change that mechanism should mediate the extent to which your symptoms improve- and there are very few mechanisms in any aspect of depression research other than what can work on rumination that they've taken all of those evidential steps to show it shouldn't really be a target. So we've been running for 15 years a basic science program that's applying that towards our candidate mechanisms of mind that get in the way of pleasure experience, so dampening appraisals, altered and reduced to positive attentional biases and so on. And when we are convinced something's a mechanism, then we start targeting it in the treatment. That's the kind of basic science roots to it. Very much influenced by David Clark's copy book about how he developed PTSD and social phobia treatments. He wrote a beautiful paper at John Teasdale's Festschrift about how did I actually develop these therapies? And we took that approach to how we've tried to target the positive affect system in ADepT Rachel: So systematic research. It sounds like both you and Paul Salkovskis like to be productively provocative. So you've given us a really good sense of the overall focus of therapy. How might that translate into what a therapist might actually do in therapy? And I hear what you're saying about you're not necessarily taking a manualised approach in a kind of paint by numbers manner, but what would a good course of therapy typically look like if you can say such a thing? Barney: Well, so just to be clear, I think where manualised treatments work really well is where you have a very clean and clear phenotype, so a particular clinical presentation walks through your door and you can be fairly certain mechanism X, Y and Z will be there and they need intervention elements, P, Q and R as a result. And that's why I think anxiety for CBT works so well. It's a more homogeneous presentation. If someone comes in with social phobia, you are pretty likely to see these things there. Depression is by definition, much more heterogeneous. It can be any combination of 10 symptoms and there are many different forms of presentation. So if you try and do the same things with everyone, it's going to be trying to squeeze a round peg into a square hole. So ADepT is all about training therapists to be good at that pattern matching. Rachel: I remember you saying, Barney, to me once when we were talking about exactly this, I was used to working very closely with anxiety disorders and we were talking about treating depression. there's something, something just feels more difficult about it. And I think you described it as the difference between a sniper approach and guerrilla warfare. And that really stuck with me and really helped me in terms of those formulations. Barney: Yeah, have to, you have to, you know, when you're doing guerrilla warfare, you have to take the opportunity and pop out and do what you can at the right time. So when a mechanism raises its head, that's when you work on it. You can't say in session four, I will always work on dampening appraisals and that will be relevant. You need to look for the opportunity when dampening appraisals are around and then choose to work on them. So with that in mind, how did we design ADepT? So it's a therapy of three parts. The first eight sessions we described was a bit like doing an A level in wellbeing. It's where we introduce the model and the tools of therapy. We start by giving a rationale about why it might be useful to grow a positive muscle and reconnect to wellbeing and learn to live well alongside depression. Then we do mood diary, like you would in the conventional CBT, but very much more interested in where are the moments of light. Where are the things that slightly lift mood? And we do a lot of solution focused inquiry. And we're just curious about what was it about that, that slightly reduced the darkness or maybe even turned the light on. And then we use that to populate what we call the values dartboard. So we split the world up into roughly four areas, work, hobbies, relationships and self-care. And we're trying to get to what makes clients want to get out of bed in each of those areas and how much of that stuff are they getting? And how can we help them get more of that stuff so that life is, work's going a bit better, relationship's going a bit better, hobbies are going a bit better, and they're looking after themselves as they go. And critically, that clients are getting a balance right between those two areas. So know, maybe Barney's values dart board is a bit too work occupied and I need to shrink that so I have time to go skiing with my kids. So that's kind of sessions two and three is clarifying values. And then we start activating people towards goals consistent with those values. And we say, this is where we really expect depression is going to come in and trip you up. And then we introduce them to a simple mapping tool, bit like Chris Padesky's hot cross bun, but with a few tweaks to understand how depression sometimes trips them up, but also just as well how things sometimes go well and they do something different. The tweaks we're bringing into that hot cross bun are we're taking a utility-based approach. So what is most likely to get you what you want here? So we start with going, what was the activity and the goal? And what were the consequences? Did you get what you wanted? And then we're thinking about patterns of thinking, attending, physiological regulation and behaviour to see, does it help clients achieve that goal? We're also building in a strong emphasis on self-care. So what are you doing first to create the opportunity for this to go as well as it could? And also, we have an environment element. How was the broader world helping or hindering you there? So what we can do is we can map out a depressed me. This is how depression tripped me up. And then we can start to move towards a new me. If I was trying to achieve this goal, what would be most likely to get me those consequences? We use that as a vehicle for loads of behavioural experiments. Like, okay, so maybe you could try a different thought on for size. I don't know if it's accurate or not. Let's see if it's useful. Maybe you could work on a different behaviour. And so I think most CBT therapists are very familiar with negative virtuous circles. We're trying to build here positive virtuous circles. Maybe the idea is if you think in this way, it makes it easier to behave in this way, which is more likely to get you your desired consequences. So where have got to so far? We've introduced the model, we've clarified values, we've introduced a mapping tool to formulate how depression trips them up. And then what we're also introducing is very systematic techniques to just consolidate positive experiences. We do regular positive journaling at the end of the day. What’s an opportunity taken? What's a challenge met? What did I do that helped? And we also get people to engage in what we call everyday simple pleasures but being experientially engaged and when they do it. So most clients like me, I've already spent £2.50 on a coffee this morning. I barely tasted it because I was prepping for this podcast with Rachel. And what would it be like if I stopped and fully engaged with the sensory experience around it? Rachel: I'm now feeling responsible for having destroyed your coffee. Barney, I'll buy you another one next time we see each other. Barney: Or another way to think about it is you've given me this great opportunity that's really values consistent and aligns with my personal meaning system to talk about work I really love. So thank you, Rachel. So we've introduced these techniques in the first third. Second third is putting them into practice to get clients to, okay, so if work was going to look 20 % better in the next few months, what do we need to change? Hobbies, relationships, and so on. And then critically, the last third is about how do we then turn this into a habit for life? What I found with classic depression relapse prevention plans is you build them and then clients put them in a file drawer and forget about them because you've got them better. And then six months later they go, what was it I did in that CBT stuff? It helped and they've forgotten. Whereas instead we're saying these are habits for life that if you keep going will sustain your wellbeing and make you less vulnerable to relapse. So using the language of Jon Kabat-Zinn, he talks about mindfulness is like weaving your parachute every day so that when you need it, you can jump out of a plane. But we're not just saying that in terms of, should you have a big mood challenge, you know how to manage it. We're also saying these are the skills you need to live well every day. So it an ongoing habit. And then because a lot of clients told us that the end of therapy feels like a cliff edge. And this is another thing, when you actually think about therapy from the outside, how many other close, caring, supportive relationships would have such a cliff edge ending as we do in classic CBT? Clients said it felt like it was great. I've got on with someone and then I never saw them again. That was so weird. So we offer booster sessions over a year, five flexible sessions that people can use as they see fit to continue with the progress they want. The structure of therapy is very similar to a CBT session except it's geared to overcome the client and the therapist biases to attend to the negative. So the first question is tell us about something that's gone okay this week, maybe an opportunity that you've taken or a challenge that you've met. So clients know I'm going to have to think of something to talk about. And the review at the end is, you know, what are the two or three things that you found useful in today's session and how are you going to put them into practice? So what we're trying to do is recalibrate the balance of sessions to notice strengths and better things. Rachel: Amazing. Can I ask about each of those stages a little bit more? So the values work at the start. Sometimes when I speak to clients about values, they look very blank. What's meaningful and valuable for you in life? And I can imagine if you've got a long history of depression, even harder potentially to engage with that. Are there tools you use to help people identify and connect with what's meaningful and valuable to them? Barney: Well, so I'm a big ACT fan and here's my critique of act. It sometimes feels like a very intellectual exercise, and it seems to lead people towards kind of, you know, apple pie and motherhood as well. This is what I'm supposed to say I like. From ADepT, we're much more trying to go from small positive exceptions that are happening in everyday life to start to explore what was it about that that floated your boat. So let's say a client comes in and goes, it's been a really tough week, but I did at least manage to get my dog out for a walk on the beach. Okay, so. And then we almost do the opposite of the downward arrow that would get you to a negative core belief. We do, this is borrowing language from positive CBT, we do the upward arrow, which is, okay, so you were out with your dog on the beach. What was it about that that floated your boat? Well, I suppose I'd like to be now in nature bit. Okay. So you being out in nature a bit. What is it about being out in nature that matters to you? And you're trying to get to the highest level of abstraction you can and go well, I'm wondering here if we've started to form a hypothesis that one thing that floats your boat is pets, if that's true, how about we test that out as a behavioural experiment? What happens if we get you to do a bit more of that? If that also lifts your mood in the same direction, that's starting to tell us what's important to you. So I sometimes use the language if it's like, maybe you're the kind of kid who's never had the chance to work out what your style is in the clothes you're in. So I'm going to take you to a clothes shop, I'm going to get you to try on loads of different clothes and you're going to walk around with them for a couple of weeks and see which ones feel like you. So we're getting there through behavioural experience, we're not getting there through intellectual abstraction. Rachel:  So it's from data and experience rather than just this actually quite terrifying blank canvas for some people when they're just asked to say, and maybe there's that pressure to say what you think you should say about meaning and values in your life rather than to really explore it as you say from experience upwards. Barney: Yeah, so one of the ADepT principles we give for therapists is just go from the informal to the formal. So I think in CBT we quite often explain the rationale and then we get people to think how does it fit them. In ADepT we're allowing conversation organically to explore areas. When we've switched something on and we've experienced it, we brought it back into mind, then we introduce the formal framework afterwards and that changes it a bit. Just a clinical example about how difficult and challenging that is, we've done a lot of co-design work around ADepT and one of the service users that has helped us do the work is called Katie, she's happy for me to use her name. She talks about at 30 after a reasonably long history of inpatient and outpatient mental health going, she didn't know at 30 who she was as an adult. One example she goes is, am I the kind of girl that wears make-up or not?   I said, I don't know, should we try it out? Her therapist, Megan, tried it out with her and it was doing behavioural experiments. Let's put some make-up on, see where that goes with you. What's it like? So you can try this stuff on for size in small steps, not suddenly flooding people to expect to know exactly what floats their boat. You can, almost the end goal of therapy is, I've got them much clearer map after 20 sessions of what's really important to me. So now I know how to live my life. Rachel: It sounds like a really lovely approach, especially for those people who miss that sort of developmental window where they are culturally supported to try things on for size and see where they fit. Actually, often people with these early traumas or long-term experiences of depression just haven't had that opportunity, have they? Barney: Yeah, absolutely. But I'm also struck by when you live with depression for the long term, the fear of falling back into the abyss actually paralyses you. So you feel like you're walking through life on a tightrope. And if I take a step the wrong way either side, I'm going to crash down into the ravine and break my legs. And what that does is it makes you see the world as one ginormous series of threats that's going to reactivate my triggers. And in a sense, what we're trying to do is just to get people to rediscover that curiosity and playfulness. We're trying to get them to reframe us. Think of life as walking through a forest. There are loads of paths you can go down. Some of them will be cul-de-sacs or get you somewhere dull or somewhere painful, but lots of them are really interesting and fun. And if you get to one that doesn't work, you can always just turn around and come back. So we're trying to move people from an all or nothing, and unless I get it right, it's going to be awful to I can play with this. I can experiment with it. And that's a big part of the therapist style in ADepT is be open, be curious, be interested, see potential, even amongst the difficult and the dark. Well, I'm sorry to hear you've had a really difficult week, but what can we learn from that about how your depression's tripping you up? How can we give you new skills here? Rachel: So it sounds like that black and white thinking can be applied to the positive equally as to the negative. Barney: Yeah, well, and we definitely see that unless it's a perfect 10, it's not worth having. So that means people are constantly monitoring is my half term trip with the kids a perfect 10 or is it like most half term trips with the kids where it rains a bit and they're sometimes a bit bratty, but we still have some genuinely fun moments. If your depressed mind says, well, there were those difficult moments, so it's all useless, that snuffs the candle out instantly. Rachel: So that's really helpful in understanding that values piece is a process of discovery and creativity. You talked about the mapping tool at your next stage. I'm thinking about bridges for people who are working in other ways. It sounds a bit like behavioural activation, work in standard ways of treatment, thinking about traps and tracks. Is there a similarity? Is there a parallel there?   Barney: There's definitely some traps and tracks, but it's actually closest to Chris Padesky's Strength Based CBT, one of my favourite papers in CBT. So read how she talks about, you can use a hot cross bun to formulate challenges and difficulties and what trips people up, or you can use it to lean into what allows them to run with good stuff. And you can do that both around the good and the bad. So you can formulate this really difficult thing coming up. Maybe it was, I had a really difficult encounter with my boss at work. I could formulate all the ways my depression tripped me up, or I could formulate all the ways I was able to be resilient, so I still managed to get through that meeting and achieve my objectives. So you're putting, you're using your simple CBT, hot cross bun, to formulate in a strength-based solution-focused way, what can I do here to get closest to what's important to me. Rachel: Then you move on to the systematic techniques to kind of build on that, enhance that, it into day-to-day life towards wellbeing. These sound like techniques that we could all benefit from using, is that right? Barney: Yeah, mean, absolutely. So when we're training therapists to do ADepT first, it's really natural as a therapist to have a whole set of reservations about doing this positive stuff. My clients are going to find it so invalidating, it's going to be a bit yucky, they're going to throw up all over my shoes and it's going to be awful. I couldn't do that. My job is to talk about the difficult. So how we get therapists to learn ADepT is try this stuff on for size with yourself and see how it lands and try it on even at times you're struggling a bit or there's a bit of darkness. And a lot of my therapy team would say a lot of us are now thinking about what's important to us in life and how are our patterns of mind tripping us up and how can we go in an opposite direction. For me, it's an interesting empirical question of if you're starting to move towards wanting to build wellbeing and a values consistent life and acting opposite to mechanisms of mind that do it, have we really invented a depression treatment or have we invented a fairly trans diagnostic life coaching approach? That it doesn't matter if you're depressed or anxious or you've got an eating disorder or whatever, we've all got patterns of mind that trip us up. We all could benefit from moving towards stuff that's more important and values consistent for us. Rachel: and drinking a coffee mindfully. Barney: Well, so that is another interesting aside. So the classic rationale for mindfulness-based cognitive therapy. So I've ended up running a mindfulness service despite my kids accurately describing me as the world's least mindful man. What I was struck by in the rationale for mindfulness is it's all about when negative reactivity gets switched on, how can you cultivate a non-judgmental, non-reactive observing mode of mind to stop you going back down the negative rabbit hole. But I was struck by the bits of mindfulness that engaged with me more, is it became a tool to let in a bit of light. So rather than just drinking the coffee without thinking about it, realising there's quite a lot of sensory experience in this. How does it smell? How does it taste? How does it touch? And so on. And realising that slightly enriched the experience. And also realising that capacity to observe my patterns of mind. Oh, there's me judging this isn't the perfect 10. This isn't as good as the flat white as I had last week. So therefore it's useless. Oh, there's that old familiar thought. I can just step away from that and come back into the sensory moment. So I'm increasingly interested in maybe one of the active ingredients of mindfulness is how do we build the positive? indeed we've started to show that that is important for mindfulness- based cognitive therapy, having relapse prevention effects. The extent to which you switch back on that capacity to experience the positive stops you getting depressed again in the future. Rachel: I was reminded as you were talking there about clients throwing up on therapist shoes, all this kind of positive wall of positivity hits them and they're kind of engaging in this different style of therapy where there's therapist cognitions that people have. It reminds me of a myth that certainly used to come up a lot talking to people about CBT, maybe therapists transitioning from other approaches and modalities. You know, they would think, isn't it just all about kind of positive thinking and replacing your negative thoughts with nice positive ones and just decide to think that the world is a nicer place. Does that come up when people are learning about this positive affect focus or the idea that you're not really getting to the root of the problem? It's all quite surface oriented, chopping the heads off dandelions or just convincing yourself that they really look rather nice on your lawn. Barney: Yeah, I mean, it definitely comes up. I'm someone with what I'd call well-managed depression. So I've probably had 15 or 20 episodes in my life. I do very well on a maintenance dose of Citalopram as an antidepressant. And I've thought really hard about lifestyle factors that help me stay well. And I've learned that the things that help me stay well and manage the depression are not feeding the beast, feeding the other side of stuff. So my world is simultaneously nearly always a mixture of the bad, the meh and the good and it's useful for me to have the attentional choice about where I direct my attention. Sometimes I need to attend to them now, like this morning I had to put some washing on, do the washing up and blah-de-blah-de-blah, you need to have that capacity. Sometimes it's really useful to be able to look at stuff that you're stuck with, it's really difficult, isn't going well and that's the evolutionary function of depression, is things aren't going as we wish, retreat to your cave, lick your wounds and change tack. But we also need the capacity to lean into the good and go, there's an opportunity here. Oh, look there's a new field I could forage, there's a new source of food. And what we need is a balance in our minds to at the right time, switch on the right mindset. Depression's trained us to be really good at leaning in to the stuck and the difficult. And we've basically got an impoverished positive muscle to lean into the opportunities. And so it's just getting clients to go, there's a choice here about where you direct your attention and you don't just want to follow a habitual pattern. You want to be able to make a wise choice at that stage. And it's definitely not easy to do that. When you are flooded with a lot of negative affect and all you want to do is retreat to your cave, shut your curtains, stay in bed, ruminate on things, realising actually what I need here is to get out and do something that normally would nourish me. It's really hard. That's not the easy choice, but it is the wise choice. So I'd say it's not just about thinking positively. It's saying you've got a choice with this complex world. It's a mix of the bad, the good, and the meh, where do I need to direct my attention now? Rachel: And it sounds like your personal experience gives you lot of credibility and authenticity when you're approaching these issues, both as sort of academic problems, but in real life, in real people's lives and experience. And you're not alone, I think. You can't be alone because depression is so prevalent and just human experiences that we always have ups and downs in life, whether we kind of experienced depression recurrently or not. On the face of it, focusing on positive affect might seem like a preferable approach for therapists managing their own stress and life challenges and ups and downs and maybe depression. How does this work apply to therapists themselves and how might they be challenged? And is there a risk they become avoidant of their own negative affect or are there assumptions they need to challenge? How do people look after themselves? Barney: Well, before I answer that, I'm going to say that the pitfall with ADepT is people think it's just about pivoting to only talking about the positive. If you just do that and you neglect the negative, it is going to be invalidating. You need that equal focus. So let's for example, hypothetically example, could be a client that's come in, she's self-harmed four times this week because of ongoing conflict with her boyfriend, but she did manage to get the dog out for a walk on the beach. If I just say, hey, I don't want to hear about the self-harm, I don't want to hear about the argument, I just want to tell me about that walk with the dog on the beach. What's the point there? You need to honour and validate the difficult enough to go, so what I'm struck by is it would have been so easy to carry on with that cycle, but somehow you've exited that cycle of self-harm and arguing to be able to do something different. So could we think from that really difficult, challenging moment. What did you do there that stopped the descent or allowed you to turn the corner? So it's not that we're not talking about the difficult, we're talking about the difficult in a different way, which is what were the strengths and resilience you brought to it that stopped that getting stuck in that? And then despite all of that difficulty, you've still managed to do some good stuff. And what was the strength and resilience you brought that allowed you to engage with that positive thing, to show that real grit and resilience that allowed you to get back into life. And if you talk about it in those ways, then when you turn to look at the good stuff, you're not giving clients the message, hey, life's all great, you just need to smell the roses. You're going, you can find good stuff, but sometimes it's really hard work and well done you for managing to lean into and engage it. And was it nevertheless worth having? I guess I'll go back to the example of my dad dying of cancer. Am I glad we hooved around in the garden, driving the mower and ruining the plants? Yeah, was one of my favourite ever memories of my dad. In amongst a lot of difficulty, I'm glad we created that opportunity. And that's the kind of language we're using with depressed clients as well. So what's it like as a therapist to learn ADepT? Superficially it feels like, that'll be really easy to learn. I can do that already. And therapists are then really surprised at how well trained they've been to attend to the negative and how all of their automatic behaviours are. Great, I caught that negative automatic thought that switched on negative affect. So learning to pivot away from that is surprisingly challenging. It's a bit anxiety provoking, like trying on a new behaviour in public and worrying you're going to be judged negatively, learning not to do that. There's also a sense of people realise it's really hard work to validate the difficult and keep pivoting towards the light anyway. It's hard work for the client, it's hard work for you and it's tiring. So those are the challenges of working this way. But the opportunities are, therapists starts saying, do you know what, to be really honest, I'm not sure I've looked forward to my depressed clients coming to see me each week for the last 10 years, but I'm starting to a little bit because I know as well as working in that really difficult stuff, they're going to tell me about, I've got back to tango or I managed to go on a date night with my husband or whatever. So it brings a different feel into the room that the therapist enjoys a bit more. And similarly, clients start to say that. I mean, how many clients go, okay, I've got to gird my loins and go into therapy and talk about all the really difficult stuff. It's going to be really painful, but I'm not sure I really like my therapist, or they like me. This is a process we need to go through, like going for a root canal at the dentist. Maybe therapy doesn't need to be like that. Maybe you can also go, yeah, this is fun. I can go in, I can celebrate some of the good bits. I can belly laugh. It's okay to experience the good even amongst the dark. That doesn't mean the dark isn't there. And what we've generally found is quite a lot of therapists start adapting themselves and they use it to, they find it as quite a useful kind of life coaching approach really. Rachel: In a small way, when I've been doing this or aspects of these techniques with clients, I can really identify with that. Those moments where you're enhancing the positive and seeing that positive affect spread across someone's face and maybe seeing them smile for the first time in therapy. It's, it is incredibly rewarding for as a therapist just to experience that affect in the room, even when it's a core part of our work to sit with the difficult and the negative as well. So you've talked a little bit about some of the challenges people experience. Where are the places people get stuck with this work? What are your most frequently asked questions in supervision or the trickiest issues that come up for therapists working in this way, do you think? Barney: So I think one of the things is it's deceptively simple to say just reorient your attention as a therapist to notice the positives and they have all the same mechanisms of mind clients do around that. So their attentional bias is much more towards the negative and the minute the positive starts to switch on, therapists then have a whole set of appraisals like, I shouldn't be talking about this. They're going to find me invalidating and so on. So it's teaching therapists to learn a new habit, which is why we just like in mindfulness would encourage people to learn it from the inside out first. Experience this, learn that it works and it's okay. Usually I say to people, because a lot of people I train are 30 to 50, so they might have kids, I go if you can get this past your teenage kids, you can get it past anyone. Getting them to experiment with these kind of ways of questioning with their teenagers and go, oh my God, even they swallowed it. So maybe I can do it with a client. Rachel: That's a tough audience. Barney: Yeah, well, exactly. If you can do it with your average teenager, can do it with anyone. The second thing that people find difficult is this is, to come back to that military metaphor, it's not following a manual. It's like being a sniper in the jungle. So how do I know what technique to pull out at what time? The challenge we're having training therapists to do is to be really good at pattern spotting. What's the psychological mechanism we're working on now? So when its around the difficult, yeah, we call them the three horsemen of depression, usually avoidance, rumination and self-criticism. So when clients are avoiding, what are the two or three evidence-based techniques I can experiment with using with them when they're ruminating? What are the two or three evidence-based techniques I've used with them? Yeah. When they're being self-critical and so on. Then get training clients to have that pattern matching approach where they're going, this is the mechanism at play, so this is the intervention element I need to pull out, is a bit different than saying in session four, bring out a negative automatic thought record. Rachel: Okay. So Barney, let's talk about effectiveness and efficacy. We started out by saying, you know, we've got good evidence-based treatments for depression, but you know, at best, perhaps they're kind of helping a third of people into recovery in the longer term. Is ADepT effective and is it equally effective for everyone? Barney: Okay, so I'm going to take a step back. The first evidence people need to know about is anhedonia- clinically important. So when you speak to clients, they say it's more important to their recovery than symptom relief. And when you look at the prognostic importance of anhedonia does it predict outcome? It predicts a whole loads of outcomes. So anhedonic teenagers are more likely to get depressed. Anhedonic depressed clients are less likely to seek help and benefit from help. Clients who are left with residual anhedonia are more likely to relapse or have a chronic partial recovery. So it's definitely prevalent and it's definitely prognostically important. The next bit of the evidence people need to know about is, cause a lot of, you know, very legitimate critique is Barney maybe you're just not very good at CBT or BA, when I do CBT and BA I get positive affect back up to better. We don't need to reinvent the wheel here; you just need to be better at CBT. So the way we looked at that is we've gone back to some of the best trials in the depression field, so led out of the Beck Institute and others, and we've looked at how well they normalise negative affect versus positive affect. And the story goes something like this; people are further away from general population averages around the positive and the negative, therapy and drugs repair positive less than negative. So at the end of otherwise successful therapies where negative affects go back to general population typical levels, positive affect is still robustly well below general population averages. And that is the same in CBT. The next critique I've tended to get is, well, but BA, it's a reward focused treatment. Surely BA is better than that, than CBT. And so we did a secondary analysis of a very big trial called COBRA, which was a head-to-head of BA and CBT in NHS talking therapy settings. And it's the same story. BA also isn't very good at repairing anhedonia. I think because it behaviourally activates people, but it doesn't teach people how to overcome the psychological mechanisms that get in the way of enjoying that activation. It's like taking the horse to water but not teaching it how to drink. So the last important piece is if you target the positive affect system, will that genuinely lead to long-term wellness? So we've done a secondary analysis of another big trial called Prevent which is Mindfulness-Based Cognitive Therapy for people with three or more episodes of depression, does it help people stay well? Where they also included a positive affect measure and somewhat surprisingly, what we found was having low levels of positive affect predicted relapse over and above all of the other residual symptoms of depression that people had. So reduced positivity was a stronger predictor than residual symptoms. And the extent to which mindfulness-based cognitive therapy switched back on positive emotion accounted for the clients who stayed well over the longer term. So I'm now really confident in saying there's a very strong evidence base that positive affect is prognostically important. Current treatments don't fix it perfectly. If they could, you would help people stay well for the medium to long term. Then it becomes a more open empirical question of, so are this new wave of therapies like ADepT any better than CBT and BA at achieving that goal? And let's just be really honest here. This is a really tricky problem. Beck was an absolute genius. No one's been able to do much better since. So just need to come at this problem with humility. Even small gains in this area are probably worth having, but they're not easy to get. And where we've got to with ADepT is the strongest evidence for it so far is we did a pilot trial head to head of high intensity CBT delivered under ideal circumstances to ADepT where we randomized 80 patients with depression with anhedonic features to either of the arms. So it's a pilot trial in that it wasn't powered to definitively test is ADepT better than CBT. To do that, you need a big trial with about 500 people because the gains you're looking for are relatively modest. But from that pilot trial, what we can conclude is we're pretty certain ADepT is no worse than CBT. So it's got less than a 5 % chance of clients doing worse in ADepT relative to CBT. And it's a bit of a 50-50 coin toss of do you do the same with ADepT and CBT or do you do better in ADepT than CBT? So we would say that is promising evidence that it's already a viable therapy. We're pretty sure it's no worse and it has a good chance of being better, but we now need a bigger trial to test that out definitively and that's what we're moving on to next. The other source of evidence in that trial is also the health economics of it. So if you want to implement something in the real world, you have to be able to show it adds value for an affordable amount of cash. And it looks like ADepT has the potential to what's called health economically dominate CBT. So it costs the same to deliver, but because of this wellbeing focus, returns more quality of life, so you get more bang for your buck. The other really interesting thing in the trial, and again, we're underpowered to answer it definitively, is what were the long-term outcomes? So I'm just going to give you the numbers and you can say whether they seem convincing or not. In the ADepT arm, we got 80 % of people into diagnostic remission post-treatment. And in the CBT arm, we got about 56 % of people into diagnostic remission. Of those 80 % who hit diagnostic remission after acute treatment, only 25 % of them relapsed over the next year, whereas 50% of the folks in CBT relapsed over the next year. So basically, ADepT s getting more people better and keeping them better for the longer term in this pilot trial, which suggests it might have potential to be a more effective treatment. But now all we need to do is take it into a big trial and critically not just do it in my little ivory tower bubble of the clinical setting I work in, which has got great therapists who are really well trained and supervised to see can we pull this off in the real world. So I'd say it's encouraging, but not yet nailed on. It's not worse, it might be better. It's also worth thinking or acknowledging that ADepT is only one of a number of emerging positive affect therapies that are coming out. There's excellent work being done from Michelle Craske around positive affect therapy in California. There's excellent work from Charlie Taylor developing a protocol called amplification of positivity for social anxiety clients. There's brilliant work by Nicole Geschwind taking Fredericke Bannink’s positive CBT and evaluating it. So I would say if you put those therapies together, is there now a credible evidence base that they're doing better than classic CBT and BA at repairing positivity? I'd say just about yes. Are we yet at the point of saying any one of those emerging therapies is definitely the one you put your money on and remortgage your house on? I'd say no, it's an open empirical question. Rachel: Impressive early data, certainly. And I wonder if the numbers are too small, the studies are too small at the moment to say anything about diversity within that. Are there people you think, or even have a hunch that this might be more effective, helpful for than others? Barney: Well, let's come back to the question of size. If you look at most of the sample sizes in most of the trials of CBT for most disorders that we would say these are really good evidence. They've typically had less than 100 people in and they've usually compared them to a waitlist or treatment as usual condition which is a really easy bar to beat. Doing something is usually better than doing nothing. So we're quite happy to say the evidence base for anxiety disorders or eating disorders or whatever is really robust and strong on trials that size. Depression's kind of a thornier problem because we've got pretty good treatments and you're trying to say, can we do better than them? So to run those trials, you genuinely need about 500 people because if CBT is, 50 % optimized, moving up to 60 % optimized is worth having, but you need a large trial. And there's just not been enough funding around to do large trials of those kinds. So I would say it is early data, but it isn't early data. We're just setting ourselves a more robust evidence-based bar around this depression stuff. But now to actually answer your question, can we say anything yet about who might particularly benefit from ADepT or not. You're right, the numbers are too small to do that in a statistical sense. So these are my clinical hunches around it. It works best for people who've tried quite a few therapies. They feel like I've done the talking about the difficult and the distress to death. I want something different. And so we're increasingly now trying it as a what we call a non-responders approach. I've tried low intensity NHS Talking Therapies, I've tried high intensity Talking Therapies. I'm still not better. What do I do next? I'm looking for something different and I'm ready to move to this position of going, I'm not sure I'm ever going to be able to eliminate my depression, but maybe I can tame the beast a bit and live well alongside it. Those are the folks that anecdotally do better with it. I'd also say if clients aren't saying experiencing pleasure and joy is a challenge for me and something I want more of, well, why would you give them a therapy like ADepT? If a client is saying what's really bothering me is I've got loads of intrusive negative memories coming in, they're not PTSD but they're making me very depressed, I'd probably think, well, you know maybe EMDR. If a client was saying, I've got loads of negative beliefs about self-world and future, and I really want to bring down my negative affect, I'd say classic CBT. But if a client's really anhedonic and they're saying, this is something I'd really like to work with, and I just never had any traction with it, that's where I'd be thinking, ADepT worth a crack. Rachel:  So Barney, you've worked with people with anhedonia in the context of depression and other problems for a long time now. And it's always such a privilege, isn't it, to work with the folk we work with. And we often learn more from them than we do or possibly than they do from us. And you've also worked with people at every stage of the development, implementation, testing of your work and thinking about developments in the future. What have you learned from people you've worked with? Barney: Lots in short. The two service users that have most helped me with the co-design of ADepT are Nigel and Katie. So Nigel helped me in the initial development of ADepT and Katie's helped me with more recent iterations for more complex depression. What Nigel encouraged me to do was to be really bullish about going for well-being and positive affect, not just trying to reduce anhedonia but getting people back to meaning, connection and pleasure and encouraging me to go further about doing it earlier with clients and that they wouldn't find it invalidating, they'd find it helpful. It had come from his own experience of being a participant in an MBCT trial where what really helped him work through his depression was reconnecting to the light. And Nigel also brought a whole range of broader experiences in life. We know wisdom as a professional in another field and lived experience to help us think about how to do the values work and do the coaching piece really well of ADepT. Then Katie basically reached out to me a couple of years later and said, I've heard about this ADepT work. I think you should be doing it with more complex cases because I spent a lot of years going through a lot of treatments that have helped me to some extent managed symptoms, but I'm still left with a sense of I'm not sure who I want to be or what matters to me in life. So she's encouraged us to set up this line of work for what we're calling complex depression. These are folks with a complex early trauma background that's leading to difficulties with regulating emotions and relationships alongside depression and anxiety as adults. You might recognise that as a description of personality difficulties or disorders. We're choosing to call it complex depression because we think that has less problems as a term. So we're just completing a case series with 30 people to see can you do this well-being recovery-oriented way of working with these more complex presentations and the headline is it looks like you can. The changes that Katie encouraged us to bring into that protocol were first of all that the values work is really hard if you've never had a chance to work out who you are and who you want to be because life's been very coloured by mental health from a young age. So go slower and leave more space for exploration around values. Also the need to bring in some additional work on giving people emotional interpersonal regulation skills, which is how we've brought ADepT into adept dialectical behaviour therapy elements in a solution focused fashion. And she was also saying, how can you manage the reality of quite often chronic fluctuating risk with these clients, which might be around suicidal urges or self-harm urges and not to allow the wellbeing and recovery oriented focus of ADepT to be too hijacked by that. Because the way you really keep people safe is you give them a life they want to lead. So even when they have strong urges to want to harm themselves, there's a reason to keep living for. So we've been working quite hard about safety plans in a more solution focused language than classic risk commentary. Katie has also very bravely, she came to us and helped us design the protocol but then she stepped out of being someone with a designer and actually received the therapy from one of our team and that's given her an additional set of insights coming back to support us later. Both Katie and Nigel also do a lot of co-teaching and co-training with me and it really helps to get rid of the them and us between clients and therapists to be teaching alongside as equals. And I asked them before this interview, what are the things you would want me to say about Adept from what you said? I think the main thing that came out was, it really helps to let go of symptom relief as your primary aim, learning to live well alongside depression and get back to wellbeing is the thing that they found most important on their recovery journeys. Rachel: Fantastic. We're hearing a bit about where you're moving things forward in terms of these complex presentations and new areas of development. What are the next horizons in this field of anhedonia? What are the next big challenges? What are the problems to solve? The knots to untie. Barney: Well, alas, it's a slow and steady process. So the next thing we need to do is a really big trial of ADepT compared to CBT to see is it really clinically effective and cost effective when done in real world pragmatic settings. What I've seen a lot of therapy developers do is they rush straight to that big trial after a promising pilot before they've fully ironed out the implementation pipeline. And for me the devil's in the detail and this is where I think David Clark and Anke Ehlers and others have been absolute geniuses in the field. They've really recognised you get you probably get 5 % difference from one protocol to the next, but you probably get 15 % difference of whatever protocol you're doing, training people and supervising people to do it well and creating a system of care in which they can deliver it well. So we've been spending a lot of time learning how to supervise and train folks in ADepT before we do a big trial so that we know it has the best chance of working. But also if we show it works, we'll be convinced it is implementable in an NHS Talking Therapy setting. The other bits of work we've been doing around the edges is in the pilot trial we found there were a few rough edges that we were less sure how to work with, reflecting the heterogeneity of depression. So I've talked about one of those already, folks with more complex trauma backgrounds, what you need to do differently for those. Another group we're interested in is neurodiversity, because generally those folks do less well in classic CBT approaches. So we're doing a case series and have adapted ADepT for folks with neurodiversity so that we can then weave that into the universal protocol about think about this if you're working with someone with ADHD or varying degrees of autism. The other piece that we're doing is trying ADepT for minoritized groups because a very legitimate criticism is of the therapy at the moment is to paraphrase, is it a bit too white Waitrose? And will the same techniques and approaches work with people with significant more kind of life grip in their oyster and or people who've come from different cultural backgrounds? So we're deliberately trying out the protocol with those folks to work out what are the tailoring and adaptations we need to do. We're putting all of that learning into the treatment manual that we're currently writing because we want it to be a book that recognises that working with depression is, it's come back to that military metaphor, it's a bit more like guerrilla warfare, you need a variety of different skills in your armoury to bring out at different times, rather than rushing straight to a big trial, where we don't think we've quite optimised the protocol before it. Because to be blunt, what happens after you've done a big trial is therapy treatments then get locked down. It becomes a bit like a stone tablet brought down from Mount Ararat and it becomes harder to innovate and change. So we want to make sure the protocol has got as far as it can before we invest all of that time and effort and taxpayer money into doing it. Rachel: So before we have that stone tablet and people have the ultimate authority on how to implement this work, how can they learn more? How can they start to implement this in the therapy? How can they get training? Barney: Well, there's two ways that these kind of techniques and ideas could be integrated into CBT practice. And the honest answer is I'm open to either of them. You could think of ADepT as a standalone therapy that you wish to be trained in. And we do various one-day workshops and there's lots of papers I can get you to read that we can link to after this podcast. But the other way you can think about it is that many of these ideas can be weaved in in a way that has fidelity to classic Beckian CBT into the work that folks were already doing in their high intensity therapy practice. And I give a lot of workshops saying here are some ADepT informed ideas that you could weave into a standard CBT treatment in a way that's entirely consistent with a Beckian way of working. And that's how I do encourage people to learn more at the procedural level. But what I would say is remember, another one of my heroes is James Bennett- Levy. I love all his work about how to train and get people to do therapy through the declarative procedural reflective model. The best way is try this stuff out on yourself. And it doesn't need to be super formal and perfect. Just play with solution-focused questioning, positive journaling, just see how it goes. See if you can find any benefit in yourself. So you also, if you can get it past your teenage kids, if you can do that, you're ready to explore with it in your own therapy practice. Rachel: Fantastic. So in CBT, we like to summarize, as you know, and think about what we're taking away from each session. I think it's almost hard to do better than Katie and Nigel's pithy statements about learning to live well with depression and enhancing well-being. But what key message would you like to leave folk with regarding this work with depression and anhedonia? Barney: For a CBT audience, think about positive affects as though it's an anxiety disorder. People are afraid of feeling positive. So the way that you can help folks work with it is a graded exposure hierarchy back towards what they love and matters to them, encouraging them to let go of safety behaviours as they go and build alternative strategies. Rachel: Thank you so much Barney for your time and all the wisdom that you shared with us today. Really look forward to seeing you again soon and people will take so much away from this. Thank you so much. Barney: It's been a privilege. Thanks for having me, Rachel. Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    
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  • "Don't believe everything you think..."- Prof Steve Hollon on cognitive therapy for depression- Part 2
    In the second part of this episode with Professor Steve Hollon, we go beyond theory into the heart of applying cognitive therapy for depression in real-world settings. Steve shares what therapy really looks like across the spectrum from relatively straightforward to deeply complex clients and how therapists can stay grounded and effective, even when things feel messy. Resources and links Cognitive Therapy of Depression (Second Edition) Find out more about Steve and his research here OXCADAT: A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/ Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [email protected] Subscribe and leave a review – and don’t forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel Handley:  Welcome to Let's talk about CBT- Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Welcome back to part two of our conversation with Professor Steve Holland, international expert in cognitive therapy of depression. In our last episode, Steve gave us some fascinating insights into the development of the cognitive model and how we can understand the development and maintenance of depression. In this episode, Steve talks in detail and with lots of examples about how to apply the therapy to really help people with all sorts of complexity in their lives without fear of getting it wrong. So let's dive straight in. Rachel Handley: And so, if you had to put in a sentence the main task of therapy, and I know asking any researcher to put anything into one sentence is a challenge, right? But what would you say is the purpose of therapy that we need to keep foremost in our minds to guide therapy? Steven Hollon: I'll say two things if I can Rachel Handley: I'll allow you two. Steven Hollon: Then I'll say two things. The first component is, when in doubt, do. If you're depressed, don't wait to feel like doing something. You're not going to feel like doing anything. Do the stuff you would do if you weren't depressed. And then the desire will come back, but don't wait to feel like it. And the second thing is don't believe everything you think. And the most powerful way to disconfirm an existing belief is to test it in a situation that your therapist can't control. Therapists get paid to tell people they're okay, or in some cases, dynamic, tell people they're not okay and if you've got kids to put through college, that's a nice, long term life lifestyle. But, what I'll do with the client when we start out and I learned to do this with Tim Beck and Maria Kovacs and others is in the very first session say, look, we can do this a couple of ways. There's some things I'd like to teach you how to do. And I can either do them for you or I can teach you how to do them. My goal is to make myself obsolete. Is that okay with you? And usually then people say, yeah, I’d prefer that. Usually, occasionally they won't, but usually they'll say that. And I’d say, now, if we were going to help you learn how to do these things, how can we do that? Say, well, can I work on this stuff between sessions? That's a great idea! So let people reinvent the therapy each time coming through. Then you'll end the session and have something for them to do between this and the next session. And by the way, every major study that has shown an efficacy for cognitive therapy has always seen people who are clinically depressed at least twice a week in the beginning. If I have to wait seven days to meet somebody, to work with somebody who's deeply depressed, they're going to forget who I am. I mean, their hippocampus is turned over. It's a, you have to reintroduce yourself. I get a little momentum going over that first session. Give me two or three days later I can keep the momentum going like Sisyphus pushing the rock up the hill. I don't know what things are like in the UK, but I would always want the depressed client to have twice weekly sessions in the beginning. It doesn’t have to be an office, one could be over the internet and then I'll space it out later on. Maybe we get a couple of weeks in, then we'll drop back to every other week. Rachel Handley: And certainly that kind of frequency of therapy is one where we have fallen into habits of, the routine is once a week for an hour on the same day and not one that a one that services often struggle with implementing logistically in terms of this, but certainly, looking at the evidence and the good clinical practice, it seems to be a point that bears reiterating. Steven Hollon: Its for the benefit of the convenience of the therapist, not for improving clients. Rachel Handley: So in terms of therapy, then it's don't think about it, do it. And don't believe everything you think. Steven Hollon: Well, yeah, in terms of the behavioural components, don't wait to feel like it. Do it. But when you do, do a test that tests your beliefs when you do it. With the sculptor, if you don't think anybody's going to hire you, then put applications in. Let's see if you're right. You might be, in which case work on a career change, but don’t your problem is right now not that you're incompetent. You might be. Well, we don't know that yet. What we do know is you're not sending out your portfolio and until you send your portfolio out, we don't know how competent you are. So let's find out. Rachel Handley: So let's test the strategy. So keeping in mind that you've said in the manual, which is a brilliant revision, the second edition of Cognitive Therapy for Depression, that therapy is not just a set of strategies or techniques, however, it's helpful to know what a typical course of therapy might look like. Can you tell us what an episode of therapy might look like for someone coming in for cognitive therapy for depression Steven Hollon: I mean, yeah, that’s a great question. I think it depends very much on what the client walks in the door with, like the sculptor, nothing much going else going on for him, except he had lost his job, probably no misfortune of his own, but he was going about getting the next job the wrong way. I mean, he was working, but something he didn't consider work and it was just a relatively simple matter of pitting his Theory A, which is I'm incompetent versus Theory B, which is he's going about it the wrong way, which is take a big task, break it into small steps, take it one step at a time, rather than getting overwhelmed with the magnitude of the task. Easy for him. Another client that I talk about is a woman that came into one of our trials that Rob DeRubeis and I were doing, and she ended up drawing me as a therapist. She knew some of the graduate students already. She'd done her training at Vanderbilt several years earlier. And when she got back to town at this point, on the way to getting divorced, real things have blown up for her in her personal life. She's absolutely devastated. Gets back into town, talks to some of her graduate student colleagues, hears about this study, decides I'm going to be in that, goes on clinicaltrials.gov, looks up what the inclusion-exclusion criteria were, sees that we were referring out people with borderline because they could get DBT in Nashville, they're going to do better with that than with what we had to offer. She borrows a copy of DSM, looks up what criteria are for borderline, knows what to deny when she comes in for interview, gets screened into the trial, gets me as a therapist, to her misfortune. In the first session, I start the thing about saying what I prefer to do is teach you how to do this as opposed to simply do it for you. And she said no, you don't understand. I am flawed. I am deeply flawed. Something happened to me as a teenager. I don't want to talk about it. I don't think we need to, but it changed me forever. I tear up anybody I get close to. I would like to have relationships with people that I care about. But anybody I get romantically involved with, I just tear them to shreds. I become this dragon lady, tiger lady. And she said, no, don't worry about that cause I'm 29. I turn 30 in six months and I don't plan to live past 30. And the third thing she said was now I'm an incorrigible liar and you can't believe a word I say, will be a problem for therapy? And of course it won't be, and it won't be a problem for therapy because no matter what story she makes up, it's going to have coherence. Evolution constrains that if she comes and tells a story about something that got her angry, then she's going to have cognitions that are consistent with somebody did something they shouldn't. The physiology is going to be aroused, and the behaviour is going to be want to attack, which is what she did in context of her relationships. So you can work with all that stuff. I never worked with somebody quite like her before, we were 3 years and in the beginning, because she was able to coerce me into it, we were meeting daily and we're meeting pretty much daily for the 1st year. And then we drop back to a couple of times a week in the 2nd year and then spaced out beyond that time. She made a marvellous return recovery, but it was slogging and I didn’t know what we were doing half the time, so we're making it up as we go along, more complicated minds are going to take longer. Now, I know from some of the training with IAPT folks, they don't necessarily get longer. However, those folks are going to show up in the service again, as Marsha Linehan would say, you can either pay us now for DBT which is going to be a couple of years, or you can have them showing up in your emergency room, bleeding on the floor, you know, how you want to set up your systems? And what I'll encourage the folks in IAPT to do is, if you get what, 10, 12, session, however many sessions you get, go as far as you can go, but for goodness sake, lay out a cognitive conceptual diagram. So they have a roadmap. The next time they show up with a therapist, they can say, can we start here? I've covered all of this stuff. I'd like to pick up with you and, you know a new therapist, but we don't have to go through all the same ground, do we? I can show you this. I know how to do that. Rachel Handley: And what would that cognitive conceptualist diagram look like? Steven Hollon: Oh, yeah. For the sculptor, there wouldn't be much there. Just his dad used to favour his younger brother when he was younger, so he came to believe he was incompetent. And he did have a lot of other problems going on, just when he got in a tough situation, he would give up too soon. So instead of giving up, let's break it into smaller steps, make it easier to do. It's like walking up a hill. You're more likely to get up a hill if you have steps than if you have to go straight up the icy stream. For the architect, gee, this terrible, awful thing, which no great mystery was involved a gang rape when she was about 15 and her father totally blew her off. She'd already lost her mother about six months earlier. She developed the belief that nobody could ever possibly love her or meet her halfway. So in a relationship, she developed a host of compensatory strategies, what people treating anxiety disorders would call safety behaviours. And her compensatory strategies, when she got close to somebody, she wouldn't ask for what she wanted because she would assume they would turn her down. She couldn't be very direct with somebody she was starting to get close to. And she would be provocative without meaning to be because if they didn't give her what she wanted, she would then act out. And, yeah, she stayed basically 15. And those strategies were the things that were screwing up a relationship one after the other, but she thought they were protecting her from being rejected. And they weren't, they were just the thing that was causing the rejection and until she started to test some of that out we- it was Anke who had to walk me through, it was my first time walking through the reliving of the traumatic experience and Anka had to give me some guidelines on how to do that. We did. It took me about an extra month to get around to doing it, three months to talk her into it, a month to talk me into doing it. My graduate students shamed me into doing it because of course they all learned how to do that in the sexual assault centres before they ever get their degrees. At any rate, it was revelatory. She not only had this notion that she was damaged property, that no decent male would ever want to have a relationship with the thing that happened to her. She also had this notion that, which she didn't have a clue about, which was that it was so scary to think that something so awful could have happened to somebody that didn't deserve it. She wanted to wrap herself up in this really tough, film noir model role. And that was the image of herself she presented the world. What she had to do is drop that stuff and get somebody she was really getting close to, have some night where she would let down the guard, tell them everything that happened to her and see what happened. She wasn't going to do that with the current boyfriend, but she would do that with me as a therapist. She would do that with an old girlfriend that she hadn't seen for years. She invited her up to have a long weekend in Nashville, pleasant, etc. And then she told the girlfriend about what had happened to her. The girlfriend commiserated for about 30 minutes and said, you want to get something to eat? The girlfriend didn't care. Took her a while longer. We had a couple of additional pieces of information she wanted collected by people other than me. And, so we ran some surveys and the like, tape recorded. And then it turns out most people, most eligible males wouldn't be the least bit concerned. One or two would, but she blew them off anyway. She's not ready to talk with the current boyfriend but has a revelatory experience, conversation with him. He commiserates for about 20 minutes. Males aren't as good at that as female friends and said, you wanna get something to eat? He didn't care. What he didn't like was when she picked on him when she was mercurial in the relationship. When if she wanted something instead of asking where he could either decide whether he would give it to her or not, she would try to manipulate him that he didn't appreciate. So when she got past that, she was able to start dropping the compensatory strategies which she thought was protective from being rejected, that's why she was getting rejected, but it took us a while to get there. Now, maybe, having had more experience with that, of the 10 patients I worked with in the Penn-Vandy trial, five of them had histories of sexual abuse, which I do think is a diathesis. And, for four of the five, we got through stuff a lot faster than we did, but she was the first person I worked with. And I was learning how to do this for the first time. Rachel Handley: Wow. And it sounds like there's a huge range in what you say from your sculptor example to this lady who had three years Steven Hollon: That's right. And again, I think we probably could have knocked it out in a year or less with this lady, maybe even less. But the sculptor didn't need the cognitive conceptualisation diagram, wouldn't bother doing it with them. This lady until we got that on paper, that was the, we had a couple of sheets of paper. We always had on the desk every time we had a session, and we'd be talking about what could you do with this new boyfriend? What would you try? Is that risky? What's on the line? How would you like to behave? What would you like to be able to do? And if you were, the new you, and then she would go from that. Rachel Handley: So it sounds like in both cases, at both ends of the extreme, if you like, if we wanted to conceptualise it as a continuum, you're working with cognitions, that your sculptor had thoughts about his part in that he was flawed that it was a problem with him rather than a problem with strategy. But you are getting him in a very behavioural practical way to break down those strategies to test them out to do something different. With this lady there was a lot more involved in understanding why her compensatory strategies might have evolved why her beliefs what and what are maybe we might talk about core beliefs or what are quite fundamental beliefs about herself that there's a lot more working out to do in that, and a more prolonged period of understanding those strategies and testing those out Steven Hollon: Yeah. That's a great summary, next time we revise the manual, if I can, I'd like to borrow your summary. Yeah. The sculptor didn't need the heavy artillery. The architect did. And she wasn't going to take the leap in a relationship that she was with somebody who's interested in easily because it scared the daylights out of her. She was so sure that it was going to blow up on her. She wasn't willing to take that chance. So having the stuff in front of her, gave her a little extra. Rachel Handley: And this really illustrates to me something I've often noticed working with depression. I work a lot with anxiety, with trauma and social anxiety and these kinds of presentations. And often that feels like you're engaged in a kind of sniper fire. You've got a very clear set of cognitions that you go out and you test out, about blushing or about beliefs about the over generalised sense of danger in the world, you know what you're dealing with, you know what the trauma is, you know what the social anxiety is, what the panic cognition is. In contrast, sometimes working with depression feels more like guerrilla warfare. You don't know what's going to pop up when the patient comes in, what situation they're going to bring. The manual talks about being patient led in content, but therapist led in structure and that can lead to some therapist anxiety is like anything can come up any situation, shifting targets, thoughts. You've described a very beautifully illustrated, a kind of very complex piece of work that went on for a long period of time with someone who said they might, I might not even tell you the truth when I'm here, you've got some work to do to understand how things are for them. So what holds this all together when you're engaged in this guerrilla warfare and you don't know what's going to come up and you're preparing for a session? What holds it together? Steven Hollon: Well, yeah, a couple things. Number one is, I always think the patient brings the content, we bring the process. So whatever content they walk in the door with, we're going to put that into our process. And they're not that, this is where we come back to the principles, they're only a couple things we want a client to learn and if they're depressed, it's don't wait to feel like it 'cause your dopamine is not working quite yet, but then the cognitive component of that is don't believe everything you think. Let's see what you believe and let's see how accurate that is. And the most powerful way to find out if what you believe is really true is to set it up in the real world and see what happens. The architect was not going to believe, that, somebody she was interested in wasn't going to reject her until she heard a fact she was interested in. I could say anything I wanted to, the old girlfriend could say that, but you know, we got to it. Or have paid for doing that. So basic principle here is that there's certain things I want a client to do, which is, if it's depressed, don't wait. And by the way, the, sculptor was a lot easier to deal with because, for him to change his behaviour was no risk. It just meant mobilising his energy for the architect to change her behaviour. She was going to blow up a relationship or whatever else was going to happen.  For her it would make the world worse. If she was wrong, she, I mean, the world could get worse if it turned out the way she thought it was for the sculptor or wouldn't get worse, where we get better if it didn't turn out the way so easier to get somebody who's simply depressed to run a test to get somebody who's dealing with anxiety, or if it's depression superimposed on an access two disorder, which is depression. what was going on with in this case? It wasn't even access to disorder. she would make our turn for borderline, but she really, it was complex PTSD. her prior experience was such that awful things happen to people. They're in risky situations. So she was sure. So I'm not going to take this kind of risk unless you have a lot of reason to think maybe she can pull it off. We did a lot of, a lot of role playing with her that we didn't need to do with the architect and we've been role play anytime. She's going to have a conversation with the ex-husband with the new boyfriend with, my work, et cetera. We bro play. We bro play three different ways. What would be a passive way of doing it, which you usually don't ask, would be an aggressive way, which would be to demand, would be an assertive way, which is, I really like this from you. And if you do, I will do that for you, et cetera. you trade favours and we would do it all three ways. And, years later. As you have much improved and years later, ABC team wanted a symposium where people would identify toughest clients had worked with and I asked her because she was staying in touch as to what you'd be willing to do the videotapes did share as long as the camera shot over the back of her head. And we did. And one of the questions ABCG asked structured questions was, was there anything in therapy that you really didn't like? Said, oh, the role play, I hated the, I hated every minute of the role play. And a couple questions later were, what do you think was the most valuable part of therapy? Said the role playing. Rachel Handley: So, So it's just like what therapists in training say. Steven Hollon: exactly. Yeah, exactly. It's, it's,you put yourself on the line, then you take on risks and it's scary. But if you're gonna take a risk and do it with the therapist that you're paying or that's getting paid and not with the boyfriend, you don't want to lose. So there, there's sometimes when it's safer to take a risk than others, Rachel Handley: So it sounds like the unifying principle is don't believe what you think, or don't just believe what you think, and the unifing process is let's test it out. Steven Hollon: Let's test it out. let's find out what's really true. Rachel Handley: So whatever comes, that's the framework we're putting it into. Steven Hollon: And people, human beings are amazing that they can deal with virtually anything if they know what it is. It's the fantasy. It's the monster in the closet. That's really scary. It's most monsters and closets aren't as scary as the thing that you think is beyond the door. Rachel Handley: And sometimes if I'm frank, the lives that I hear about in the clinical room or in supervision across services here in the UK, do seem to support a pretty negative worldview? So we've got patients are unemployed in situations of domestic abuse of one or more frequently more long term health conditions, few social supports, custody battles, housing problems, live in high crime areas, are battling addiction. It can feel a fair way removed from a depressed sort of white collar, middle class professional or artist. Often or often students presented in kind of depression textbooks, not that depression is any less real in those cases for those individuals, but what about the patient who barely makes it out of bed in the morning and can't begin to think about how they find social and financial resources, never mind the motivation or the energy to engage in behavioural activation? Does the model really apply in the real world? That's my question. Steven Hollon: Sure. Because people are dealing with real world issues all the time, whatever their current status is, and people tend to the magnitude of the problem tends to be greater in people that have more. I mean, they see it as greater than somebody else that doesn't have as much to go with, but you're dealing with the same stuff and there's virtually nobody in a high crime area, who's not everybody in a high crime area is invariably depressed. Some things are worse than others. Nobody would sign their, 12 year old up for the concentration camp experience as summer camp, but, even people that deal with absolutely awful situations as bad as the situation is, if you keep your wits about you, you can reduce the impact on you, and it might be the best you can do, but at least get the best and move towards that. The sculptor, by the way, never got a job back in academia. When he was trying to do is interacting in the world. And in Minnesota at the time, Minnesota. Terribly cold winters. It was wintertime and he's at a donut shop. The way you get through cold winters is with fats, sugars, and caffeine. And he's reading the newspaper, finished the sports section, and some guy a couple stools over said, can I see your sports section? He handed it to him. The guy struck up a conversation. And he said, I've seen you from time to time. Who are you and what do you do? And the sculptor said, well, I'm so and so. But at this point, he was, he was done with therapy. He said, but I'm actually a sculptor by training. The guy said, sculptor? He said, yeah. Said, you ever thought about working for Tonka Toys? And the sculptor said no. He said, Tonka Toys is one of the world's largest toy manufacturers. They're out in Minnetonka, west of Minnesota, west of Minneapolis. He said, we hire sculptors. What we do is get them to turn the product design people's ideas into little scale models of the toys. Then we let the kids play with them to see what toys kids like. He went out there, he applied and got a job. He would not have gone back to academia. You don't know what you can do in the world until you start interacting in the world. And without relationships, there's always, they're always big brothers, big sisters. They're always people in the world that would benefit from having somebody a little older, who's going to take an interest in them. If there's nothing else, I'm going to go down to the animal shelter. I'm going to help feed and play with the pets. I'm going to do something that moves me in the direction that I want my life. If I ain't got it in my life right at the moment. And some problems you may or may not be able to solve. I mean, the death of a child, what could possibly be worse and the most depressogenic thing that we know about. But there are things you can do. One of the things we've learned, you throw yourself into the grief. You sit, you go through the photo albums, you have your little shrine in the home, you visit the grave sites, you might start coaching kids sports teams, et cetera. You don't cut yourself off and there's strategies that just work better than others. Rachel Handley: Reminds me, hearing you speak about this of some of the work that Ed Watkins has done in rumination and how he talks about how there are problems you can't work out in your head that need to be worked out in the real world. And going back to where we started with this kind of evolutionary principle that we're shut down, that we're intensely focused internally, the memories are primed, the short term memories there, that we're not distracted that we're trying to sort things on our head that actually need to be sorted out in the real world. Steven Hollon: It's absolutely brilliant. And he's really, he and Susan Nolen-Hoeksema might have really explored the role of rumination more thoroughly and better than anybody else. He's got some really lovely kind of approaches to dealing with that. Keep in mind when I talk about evolutionary perspective, most folks in the field, most depression experts would not agree with that. So that, and goodness knows, if you look at, my track record, I've been wrong more often than I've been right. I wouldn't bet money against Ed in the notion that rumination is the primary problem. It's not what I would bet money on myself, but, see where we go. I do think what we're doing is helping people structure the rumination. That's the adaptation of the brain involved to do when things make you really sad, then I want to facilitate the process and not leave you stuck. And I think what we do with cognitive therapy is teach people how to ruminate more efficiently. The three things I want a client to be doing when they have an automatic negative thought, the beginning of a rumination is say, what's my evidence for that belief? Any other alternative explanation for that? And even if it were true, if I don't know yet, what are the real implications? So, suppose you lose your job, first thought is, my God, must be because I'm incompetent. Well, any other things went wrong? Well, they've been downsizing. So maybe, a number of us lost our jobs. Maybe I was just the first out, et cetera. There's an alternative explanation, which is more consistent with the data. And as tough as it's going to be without my job, do I have unemployment benefits and how long do I have them for? What are the kind of jobs I want to pursue next? Is this a time when I want to take a chance in my life and try something I haven't tried before? They're the things you can do to get yourself mobilised which are not consistent with shutting down and doing nothing. And that's what we want to have clients move towards. Rachel Handley: Also thinking about complexities in who we treat, you've spoken a bit about a patient who met criteria for borderline personality disorder or EUPD. What about patients with personality disorders or longstanding chronic impairment? The manual talks a bit about a three-legged stool. Is this where this principle comes in? Steven Hollon: The biggest change in cognitive therapy since Beck first laid it out, the 1970s version that I trained in, has been dealing with more complicated clients. And the architect, the lady, we described it as a good example of that. She had a lot of other stuff going on. And the biggest problem was that she, and this is almost always the case with Axis I people with depression, superimposing Axis II disorders is that she had compensatory strategies that function like safety behaviours for her. She thought they protected her from loss from risk, etc. They didn't, but she couldn't know that until she dropped them, and she wouldn't know the role they played until she took the chance, takes a deep breath. With the sculptor, all he had to do was break stuff down into smaller steps. He's taken a risk to do that with just a matter of getting out in the garage and putting his portfolio together. With the architect, she had to take chances in interpersonal situations that she thought she had something to lose. So laying out a roadmap for her about where did this come from? When did you first start believing this about yourself? What other evidence do you have? Let's talk about the times when you have had relationships blow up on you. What are the things that you've engaged in usually out of a sense of desperation, have they served you well? Have they really served you better than just levelling with your ex-husband or with your new boyfriend, et cetera about what happened to you at age 15 and see if they have any problem with that. So for Axis II personalities, it's a matter of taking chances or giving up something that you really like. When Trump first got elected back in, what 2016, on that election we had our grad class on cognitive therapy the next night and everybody came absolutely dejected. So we talk about how would you deal with somebody with narcissism. And, say, look, if I were this guy's therapist, which of course I'm not, we'd walk out of the White House, we'd go out on the mall, I'd look, first to the left, see the Washington's Monument? You want one of those? How did Washington get that? Well, the father of our country, he gave up power voluntarily. He didn't try to, well, I don't know, at that point he was going to mobilise a mob. Then we look down the other direction, Lincoln Memorial, and say, how did Lincoln become the most beloved of our presidents? Well, he bound up the wounds. He didn't come down hard on the people that lost the war. He reintegrated them into the thing. So you look to helping out the people that are looking to you for help. You could do that as president. You'd be beloved, but you know, you do what you will. Who knew he was also a psychopath? But what do you know? Rachel Handley: We can only hope, Steve, that you get to him before the next inauguration speech, which is upcoming as we record. Steven Hollon: We can only hope, but I'm more likely to hit one of the concentration camps. Rachel Handley: And the three-legged stool, there's something about how you use the relationship in therapy as well which that sounds all very psychodynamic. Steven Hollon: And that's the biggest change in cognitive therapy. Tim and colleagues came up with that in the early 90s. In the 70s, most everybody we treated was depressed, but that's all they were, because in those days we were screening out folks with more severe disorders, and most folks were getting, 60, 70 percent were getting better within a couple of months. By the 90s, most people in the clinic were people that didn't get better fast, and they were simply the more complicated. They were the architects, not the sculptors. And, they had to come up with something different. And what Tim did say, look primarily in cognitive therapy, what we learned to do way back when was to focus on current life situation to get people to test the beliefs that lead to the behaviours that keeping them stuck in those situations. Now we got people that have essentially compensatory strategies. And those are the things that are actually getting them in trouble. You want to help them lay out where those strategies are coming from, what they think they're protecting them from, and then encourage them to test those. And he went to a three-legged stool. The first leg is what we always had done, which is focus on the current life situations and the beliefs, behaviours, etc. Second leg is the childhood antecedents. With somebody like the sculptor, I wouldn't bother talking about the past, once he's no longer depressed, rather than just talk about movies sometimes I go back to how'd you first get this way, just to tie a ribbon around the therapy, it might be a session or two at most. But the architect would spend a lot of time going back over the end of scenes where this happened, was in her mind, the rape was not that traumatic, the fact that her father couldn’t have cared less and blew her off, that convinced her that she was without value, what have you. We kind of laid that out and would then go down to what are the core beliefs that you learned. The core belief for her, it was I'm unlovable. For her, it's I'm unlovable, for the sculptor it was I’m incompetent. What are the underlying assumptions? Underlying assumptions don't reveal yourself in a relationship and you won't get hurt. If you want something, don't ask for it directly because they're not going to meet you halfway. Manipulate. And those become the compensatory strategies. And it was the compensatory strategies which kept getting her in trouble. Now, the third link is the therapeutic relationship. With the sculptor, I mean, it was like he was going to see his accountant or his mechanic. We came in, we talked, we did the stuff, and he left. With the architect, three o'clock in the morning the first week she's in therapy and I'm getting calls. Nobody's on the end of the line. You got a pretty good idea who that is. She's already manipulated me to have everyday sessions, done all kinds of things that I typically wouldn't do. It's quite clear that she's structuring the therapy in a way that's going to suit her convenience, the chance she wants to take, etc. So we lay out that third line, which is the therapeutic relationship. And anytime we put something on the agenda, how does that relate to what you learnt back when she was a teenager with her dad, and how we're working on that in here, anything about the way we worked on that, that rubbed you the wrong way? Anything reminded you about how pissed off you were at your dad or your ex-boyfriend, your ex, et cetera, et cetera. We touch all three legs of the stool. And then we'd use the interactions in the therapy session as, how would you say, they were stalking horse, and she could practice doing stuff with me before she was ready to do it with the people she really cared about out there. And there were times, there was one time she came in, called, we were starting to space out the therapies, only doing a couple times a week now. And there was a Monday afternoon, we were going to meet on Monday. I'm a big fan of a football team- we have a different kind of football over here. They're going to be on Monday night football, unusual because there's a very bad team, I really want to get home to watch the thing at eight. She calls late afternoon, can I have a session? Something happened. Okay, you have a session, but I want to make sure I'm home by eight. Is that okay? She shows up half an hour late with a hot cup of coffee. And I'll look at her and say, that’s I’ve got this depressed, maybe borderline, possibly suicidal client. I said, that really annoys me. That really pissed me off. And she gets really upset. So, we spend about the first 15 minutes going over how upset she is, pissed off. How could I do that to her? And we end up having this nice discussion where, look, I will meet you halfway. I'll treat you like a real human being if you do the same for me. But, I'll cut deals with you, but I expect you to honour your deals with me. And that she, later on, would say that was a really major breakthrough. We used that as a model for how she can deal with people that she really cared more about. And if you're going to manipulate people, be ready to own up to it. And, and if they call you on it, that’s good. But, so we put all three of those together. We did that three-legged stool model that shows up in the manual. First time I'd ever done that, but we had that on the desk. And everything we did, we go each step, each, leg in there. So you're dealing with this bossy person at work, how's it relate back to what happened with your dad? And how's it relate to how you and I are working together? We touch at each leg of the stool. And it didn't always have to, but it helped him enough of the time that for somebody who's dealing with depression superimposed on Axis II disorder, where they're used to either manipulating or avoiding or doing stuff with other people, where what they do is screw up their lives continually because of the way they treat other people it helps them understand that. And we're working on that in the therapy session itself. Rachel Handley: Yeah. So we often reflect in this podcast that being a therapist is an incredible privilege, the best, most rewarding job. But let's face it, it can be a tough one as well. Our own lives aren't always free of complications and challenges that make it harder when we're maybe we're working with depressed clients. What you've just described is some pretty complex interpersonal dynamics, the kind of having to make a decision to share your own anger, your own response to that hot cup of coffee that arrived in your therapy room. How might we be challenged by this work and how do therapists look after themselves and maintain that therapeutic stance? Steven Hollon: Yeah, that's a great question. I had 3 episodes of major depression in my early 20s; last year in college, the year between when I was working as a therapist at a communal health centre and my first year in graduate school, and nothing since I hit Philadelphia. Whatever I've been learning to do with my clients ha been working like a charm for me. And that's not usually the way the life course goes. There's something derailed the typical progression in my life. And I think it's what I learned to teach other clients to do. The second thing I learned in the whole process is that. is if you think something might be, you don't want to do things that are rude or harsh to somebody else unless you've already built a good relation, in which case you can ask for a minute and go and do that, but if you have an impulse to do something for God's sake, do it. The biggest errors we make as therapists is not acting. And its because depressed clients are not acting. They know what they want to do. In most of our trials, the toughest people to treat are people with chronic depression. And it's not usually the case that they don't have a notion as to what they could do in their life that might make it better, but they're not willing to take those chances. And, what I've learned in my professional career, my therapeutic stuff is, if you think something might be worth trying, for God's sake, try it. Ask permission first if needs be, to clean up the mess afterwards, but I think the mistakes I've made have been more likely errors of omission than errors of commission, and you've got a client you're working with, they've gotten to know you a little bit, they'll usually cut you a little slack. Rachel Handley: So don't get stuck in behavioural inactivation. Steven Hollon: Don't get stuck, don't get stuck in behaviour and not acting. Rachel Handley: I guess it's also really important to us as therapists to know that what we're doing has a high chance of, or a good chance at least, of success. what is the,effectiveness, efficacy of cognitive therapy for depression now, and is it effective for everyone? Steven Hollon:  No it's clearly not. A short term with a relatively uncomplicated person, relatively uncomplicated depressions, not chronic depression 10 to 20 sessions is going to be enough and in the last third of it you're going to be talking about other stuff. So for the sculptor, we had more sessions than we needed. For the architect, we needed more sessions than we had, although things continued on. I think it depends on how many episodes, how long the person's been depressed and other kinds of complications. If I get somebody who's depressed and has panic attacks, I'll ask if we go after the panic attack first, because that's a session or two. If I get somebody now, who's depressed on top of PTSD, I think we have to go after  PTSD first. We do the reliving quick because that I mean, you can get rid of the PTSD symptoms rapidly with the reliving, then you got all the trauma, the meaning there to deal with, but that's going to be part of it as well. And that usually moves faster than the depression per se. Social anxiety takes longer. And that's the anxiety that sort of reminds me more of depression than anything else. And it's not always the self that’s the problem its usually other people, you never know when they're going to turn on you, but usually there's a history of having been bullied something else. So there's often a self-involvement there as well. And I've not done much work with people with serious mental illnesses, at least not much successful work, but you guys have in England and you're good at it. And I remember we had a marvellous therapist out of the Maudsley that came over and did a weekend long workshop for us over here. She would describe a client and then ask people in the room what they would do. And I would usually be quick to volunteer. And I'd say something and it would be like, no that’s too soon, build a relationship first too soon. So, the one thing I learned out of that is don't rush. Got a depressed client- rush. He who hesitates is not serving his client or her client well. With somebody who's got a propensity to decompensate, take your time, let them get to know you, get to trust you, and then put stuff in. But you guys are much better at that than we are we're in the States, we're trained that you can't reason with somebody who's psychotic. And in England, you guys do it and it works. Rachel Handley: So it sounds like really important factors in the effectiveness of this therapy are going to be things like chronicity, severity, comorbidity and type of comorbidity, very importantly, whether it's severe mental illness or different problems that you can deal with. Steven Hollon: Can I comment on that? I think that's great. But I would start with that tucked in the back of the mind. I would probe to find out. I wouldn’t assume just based on, I would take my Sally's. It's like you're sending out a group to see where the gunfire occurs in the war zone. You never know for sure. And don't assume that something's going to be tough until you find out that it's tough. Rachel Handley: So someone walks into my office with unipolar depression, maybe it's the second episode in adulthood. Is there such a thing as an answer when they ask me? What are the chances of me getting better, Doc, when you've done cognitive therapy with me? Steven Hollon: Yeah, they're pretty good. And the question is, I mean, there are other kinds of therapies that work as well and great if this kind of thing works for you. By the way, it won't work if you don't take it, don't use it. It's like medications. You can't just hold the pill in your hand and expect it to do anything for you. But if you work on the therapy, try this stuff out, take a few chances, risk, et cetera, then we'll find out the odds are about 6 to 7 out of 10 that it's going to work for you, in a relatively short period of time. And by the way, if it works for you the odds are it's going to cut your risk by at least half for having future episodes. So not a bad bargain to get into, can't guarantee and I never want to make a promise, I can't guarantee. But we do know how to find out and it's to do the stuff and see what happens. Rachel Handley: So perhaps a bit controversially, we could say, well, we've reached the limits of cognitive therapy. It's going 50 years on, maybe there's a 6 or 7 out of 10 odds chance you get better, maybe less, maybe more depending on your presentation. Have we maxed out on recovery and remission now? Is cognitive therapy standing still or can it still improve? Steven Hollon: Yeah, it's a great question, but I think it's evolving. I think we've learned how to do things starting with the focus on the Axis II disorders that we didn't know how to do back when I first went through training and my hunch is most people that know how to do cognitive therapy haven't learned yet how to do that stuff. I think I'm a better cognitive therapist today than I was back in the 70s and I think I'm better cognitive therapist today than I was when I started working with tough clients like the architect. So, I think thats the trajectory for any given therapist as well. And I think I'm learning things. I've been watching the tapes that David and Anke put on the OXCADAT training tapes for social anxiety and PTSD and I’m a bit further along with PTSD, social anxiety, still a bit of a mystery. I don't quite understand anxiety, but I mean, amazing training tapes. So, I don't think we've got close to maxing out at all. Rachel Handley: And you've spoken a little bit already about the Philadelphia effect when you started doing this work, it helped you in terms of, as you reflect back, you haven't had further episodes of depression, you've been able to implement some of the tools and strategies. What have you learned most, do you think, from the people you've worked with? Is there any lesson or individual that stands out as someone you really impacted in your life? Steven Hollon: Oh, I mean, Tim Beck was just an absolute marvel. When Tim turned 100, Judy Beck and Rob DeRubeis set up a birthday thing for him, and about a dozen people came in by Zoom and we were going to share some kind of anecdote. We all basically told the same story. Tim identified something in us when we were generally early in training, graduate student, resident, et cetera, that he then nurtured over the course of our careers. And, just remarkable that, this is a guy who was an outcast in his own field, totally dismissed, totally ostracised, but he stuck to the data, and he built something really very positive out of that. He also, enlarged, expanded, what he was doing, went beyond the narrow structures in a way that is marvellous. I mean, other folks as well. I've learned so much from people like Anke Ehlers and David Clark and others and the marvellous folks down at the Maudsley; Sheena Liness and Suzanne Byrne and others, I come to, England from time to do training workshops, and I've learned more than you guys learned from me when I come. Rachel Handley: And what about from your patients? Steven Hollon: So much. I mean, you learn different things from different patients. Nobody ever worked me at and down the other more than the architect and I ended up being more of a friend than a former client, but just remarkable. And, most of the time I was flying by the seat of my pants. You trust your gut and you do what you do. And if something screws up, then you work your way through that. It's like any other kind of relationship you don’t know coming in with the other person's going to like it, you work your way through, you get feedback and you go from there. Rachel Handley: It's something really freeing. Yeah, there's something really freeing about that message around not getting stuck, not getting paralyzed in our work. Steven Hollon: Yep you learn more from tough patients. And, when I come over from time to time and get a chance to do the workshops, often we'll spend the second day, just going over, bring your toughest cases, the people you have the most difficulty with and we’ll role play around that. And sometimes we invent stuff on the fly, we come up with things we hadn’t anticipated. One of the things about cognitive therapy is Tim would always say we'll steal from anybody. And if it's a good idea, he'd incorporate it. And we keep the spirit there. If it's a good idea, then you bring it in. Rachel Handley: So it's important to pursue what works? Steven Hollon: Yeah, and it's important not to worry about whether or not it's going to work enough before you pursue it. Roll the dice, see what happens, and correct your errors. Rachel Handley: Test it out. So if people want to learn more about your work, Steve, where can they access training? You've spoken about coming to the UK and doing training here. I'm sure you're doing lots in the States. Where would you direct people if they wanted to dig deeper into this? Steven Hollon: Yeah. Well, again, you guys got, these recordings. I don't know if, Sheena and Suzanne, I usually, each year I've been coming to the Institute, the Maudsley, like I don't know if they tape those things. There are other folks I come over that I do trainings for that tape. I think in May, I'm scheduled to do three; one at the Maudsley, the other two- is there an Oxfordshire one and the 3rd place and I don't know, if they're taping those things, often they do and those may will be available. It's funny I do more training in the UK than I do in the States and because again, we're so when it comes to depression, we're so cognitive behavioural as opposed to cognitive and for anything else. Again, the basic principles you get from the marvellous training tapes that David and Anke put up on the OXCADAT site. And, I'll be teaching a course this semester, graduate course on cognitive therapy and the depression stuff I'll handle. We'll have examples and tape some things, but for the last third of the course, we'll go to the OXCADAT and watch tapes together and talk about what they have. So that again, the marvellous source of training, Rachel Handley: Fantastic. And of course, as we've spoken about a lot, there's this new manual, that, that is last published last year and really worth a look. Look, I still have my old version, my first edition, which was, and I know we're not supposed to have superstitious beliefs as cognitive therapists, but it was signed by Beck. So I'm never going to be able to relinquish that because that will clearly make me a bad therapist if I dropped the book, Steven Hollon: if you didn't have time, there's the revision. I'll be absolutely amazed but do your best. Rachel Handley: that might be beyond even my superstitious reach. So in CBT we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key message would you like to leave folk with? Steven Hollon: I would say always the cognition is primary. What somebody believes is what you really want to know. But different kinds of disorders are going to play in different kinds of ways. If it's depression, usually people aren't moving, going to be better for them if they do it. Do you want them testing stuff out? So you really try, usually trying to activate them. And that usually is going to mean taking stuff they're trying to do that isn't working well or not even trying and break in small steps of behavioural components. Very useful there. But always it's the test in the real world that matters the most. But what you want to test is the belief that they have and other things, and again, so often you get other things in the midst of the depression, the anxiety, the phobias, the trauma histories, et cetera. Yeah. find out what they've come to believe, and then, see what, see what evidence they would find compelling to help them change their belief. It doesn't matter what you find compelling. It matters what they would find compelling, then help them move on that to run those tests. Always in the session, there's going to be somebody in the session that knows the most powerful test to run of a belief, and that's going to be the client himself or herself. It's the last thing they want to do, and find out what's the last thing they want to do, particularly if there's any anxiety involved, and encourage them to do that. And when they do, then they find out whether they needed to be afraid. Rachel Handley: And I'm taking away from this as a therapist, not just that message for work with my clients, get them to test it out, But to test stuff out myself, not get stuck in that paralysis. And we can all make mistakes, but they can be fixed. they're all grist of the mill Steven Hollon: When you say this is a really tough client, that's the beginning of the conversation, not the end. And then you say, did the stuff we know how to do, is that likely to work? Let's try some of that stuff, but if not, what do I have to invent? We've got to come up and then involve the client in coming up with that. The architect was remarkable in the way she helped modify and redesign the therapy with me. Rachel Handley: And the rewards are great if we can help people live more fulfilling, happier lives. Steven Hollon: Yep. That beats parking cars. Rachel Handley: Thank you so much, Steve. It's been so interesting talking to you. As I predicted, we could have gone on a lot longer, so many questions, but this has been really helpful. Thank you very much for your time early out there, in the States. So thank you for joining us. Steven Hollon: Been a great delight and thanks so much. Much appreciated. Rachel Handley: Well, if you've made it to the end of this podcast, perhaps like me, you'll want to go back and listen again. There is so much in what Steve had to say. We have more coming up soon on our series on depression, so watch this space and until then, look after yourselves and look after each other. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.      
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  • "Don't believe everything you think..."- Prof Steve Hollon on cognitive therapy for depression- Part 1
    In the first instalment of this special two part episode, Rachel Handley talks to Professor Steve Hollon, international expert on the prevention and treatment of depression and co-author of the second edition of Cognitive Therapy of Depression about how we understand and treat depression. Steve shares what first drew him to the field, his early encounters with Aaron T. Beck and the rise of cognitive therapy, and how insights from evolutionary biology, psychology and neurobiology can enrich our understanding of depression. Next time: In Part 2, Professor Hollon discusses how CBT can be applied to a wide range of presentations, from more straightforward to highly complex and even tries his hand at devising a brief intervention for the President of the United States. Don’t miss it! Resources and links Cognitive Therapy of Depression (Second Edition) Find out more about Steve and his research here OXCADAT: A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/ Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [email protected] Subscribe and leave a review – and don’t forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel Handley:  Welcome to Let's talk about CBT- Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. My guest today is Professor Steve Hollon, who had so much fascinating information, theoretical and clinical insights and stories to share that we just had to produce a special two part episode. In this first part, Professor Hollon shares the reasons for his fascination with depression, the story of Beck's development of the cognitive therapy for depression model and insights from psychology, neurobiology and evolutionary biology that can help us understand the development and maintenance of depression. Professor Hollon is an international expert on the prevention and treatment of depression and co-author of the long awaited second edition of Cognitive Therapy of Depression, the definitive and groundbreaking psychotherapy manual, first published by Aaron T Beck and colleagues in 1979. Professor Hollon is professor of Psychology at Vanderbilt University in the US but is no stranger to us in the UK and supporting the dissemination of evidence-based therapies here as he regularly provides training to services in the UK and teaches on the Talking Therapies Program at the IOPPN annually. So welcome to the podcast, Professor Hollon. Steven Hollon: Thank you very much. And Steve, please. Rachel Handley: So Steve, you've been working in this field for quite some time now, you might not want to tell us how long, but can you recall for us who or what got you invested in the field of depression personally and professionally? Steven Hollon: Yeah, I can't tell you exactly why I got interested in depression, but that goes way, way back. We have some family history that I got my own personal history of episodes of depression, but to make a long story short, I was in graduate school in Florida State which was good, strong program, but I was reading Aaron Beck and Marty Seligman and Jerry Claremont, the fellow that generated IPT and I was showing up, in those days we had libraries, we had stacks. And I was looking at some of the same journals that my then graduate student colleague Judy Garber, now 50 years now we've been together looking at the same kind of things and we just decided that we weren't getting the kinds of training that we absolutely wanted, as good as the program was in Tallahassee, we want to work with some of the leaders in the field. So she wrote to Marty and cut a deal with him to run his research labs while he was off on sabbatical at the institute in London. And I was finishing up my dissertation collection data and I followed her up about six months later, with the notion that I would work for Beck. Of course, Tim Beck didn't know me from Adam and couldn’t get in to see him. And his cognitive therapy approach hadn't taken off yet, but we ended up seeing that his group was going to be presenting at a conference, Society for Psychotherapy Research in Boston. So we drove up the coast and went to the meeting there and I spent the next three days getting to know the other people in this research group and, talking with Maria Kovacs, really first rate psychologists who ended up becoming a leading figure in developmental psychopathology, Hungarian and wanted to go back to Hungary for an extended visit that summer and Tim was reluctant. They had a research grant going on. She was interviewing people that survived suicide attempts. I'm just hanging out on the fringe of the group, and I said, well, I'm a psychologist, I'll stand in for it. So I stood it on a volunteer basis and spent the next three weeks trying to make myself indispensable. We ended up negotiating my first year in Philadelphia as my clinical internship. Second year, with Tim's blessing, I went over to the psychiatry residency program, continued working with him, and then ended up going off to Minnesota for a job I was thoroughly unprepared for. Nonetheless, things went well, I got an offer and went out there. Judy graciously finished up her doctoral training at Minnesota and eight years later, we were left eight years and 16 winters later, we left for Nashville Vanderbilt and where we’ve both been on faculty for close to 50 years. Rachel Handley: Wow, that's quite a trajectory. I'm old enough to remember what it's like to go down into a basement of a library and roll the stacks along and actually have to find a physical journal paper, not just type it in on the internet. Right. But from there to working at the heart of the revolution, really, of cognitive therapy with Beck and his team must have been quite something. Steven Hollon: It was something, but it was not a thing yet. Tim Beck, Philadelphia Penn was heavily psychodynamic, he was heavily ostracized. He'd been dropped by the Philadelphia Psychoanalytic Society. Every year they'd have the various psychiatry faculty meet with the residents, and when he met with the residents, virtually nobody showed up. It became a thing with the publication of the first outcome trial, the Rush et al study that suggested that cognitive therapy not only held its own with medications, it was actually better than turns out. It only looked better than because we did a terrible job with the medication comparison, but everything since that's done a good job with cognitive therapy, done a good job with medication treatment suggested they're about comparably effective and cognitive therapy has an enduring effect that cuts subsequent risk by about half something medications can't do. Rachel Handley: And as you hinted there, that was the journey for Tim Beck as well. He came from this psychodynamic background training team, anyone with a passing interest in cognitive therapy now knows about or has started by training in the principles and practice of cognitive therapy for depression. But can you tell us a little bit about his story and the development of the approach? Steven Hollon: Yeah, he was, although he was marvellous fellow, a marvellous human being, but originally wanted to be a pathologist because you could get definitive answers, but he ended up getting diverted into psychiatry. And in those days, the late 40s, early 50s, everybody was trained dynamically. He was trained by some of the best. And of course, the dynamic explanation for depression was it was anger turned inward. These were unconscious motivations laid down in early infancy, to be angry with your parents about something, some kind lack of sexual gratification and the notion was you had to, the patient himself or herself couldn't be aware of what their true motives were because there were defence mechanisms that got in the way. So you had to sneak up on them. You had to rely on free association. People would take the couch and just say, first thing that popped into their head, or you would interpret dream content, and you might spend two or three years exploring the underlying motivations without ever approaching them directly. The therapist might go, certainly better part of a session without saying anything. So it was a very long term, expensive therapy form of therapy. Tim was interested with his interest being a pathologist was interested in doing some research as well. And he was struck by the fact that the things his clients to him and their free associates in their dreams, which is like what they told him when they were walking into the office. I'm an addict. I'm unlovable. I'm a loser. I never do anything right. As, and they weren't screens for underlying, sexual and aggressive drives, They were just what they believed. He did some research where he investigated dream content, investigated free associations, and as hard as he looked, he could not find evidence of anger turned inward. It just wasn't there. He did an experimental study with colleagues across the street in psychology at Penn where they manipulated outcomes on a performance task. And it turns out if you want to get somebody who's not depressed really activated and motivated to try harder the next time, give them a failure experience. Rig it so they don't win. If you want to get somebody who's depressed activated the next time, give them a success experience, contrary to what they expect that then gets them mobilized. And on the basis of that, he started, I think, in ‘63. he was writing those things up in the late 50s, but a ‘63 article in what was then the Archives of General Psychiatry, laid out the basic notions of the theory. And in ‘64, he came back and described some of the things he was doing therapeutically, which were really almost common commonsensical, if you take your client's beliefs at face value, you have them exactly the accuracy of their beliefs, and it got him dropped by the Philadelphia Psychoanalytic Society, ostracized by his colleagues, but the last laugh, he wrote his ‘67 book on depressions now considered a modern classic an things took off from there. Rachel Handley: Well, that's the kind of failure we can all live with, right? Steven Hollon: Exactly. The one thing Tim would always say is it much like, working with people who are depressed is you always want to turn adversity to advantage. Something goes wrong, find out a way to get something out of that. Rachel Handley: That's what he did. And it sounds like, very much took that, that, that pathology approach. He was dissecting the presentation, what was in front of him and understanding it rather than the bringing theory a priori to the presentation. Steven Hollon: Yeah, absolutely. He was always driven by data, which is again given a psychiatric background, you wouldn't necessarily have expected that, but he did and he was. He also spent at least a year at Oxford in the early 80s. Michael Gelder picked up on this growing phenomenon fairly early on and invited Tim over for a year sabbatical and he did, and that's where he had contact with people like David Clark and Paul Salkovskis. And, just, in some respects, England moves a little closer to Beckian Cognitive Therapy than we do in the States. We have a lot of folks that came to cognitive behavioural approaches from a more behavioural background, and they still have a little trouble thinking about the meaning behind the belief, for them, but a cognition is just another behaviour. You reinforce that in you replace negative thoughts with positive ones, as opposed to getting people to examine the accuracy of their beliefs. So there's a bit of a contrast. And I would think nowadays, David Clark, Paul Salkovskis and Anke Ehlers are closer to Beck in spirit than the states and depression. But, most of the rest of the folks over here, particularly anxiety, stress, et cetera, are more nearly behavioural with cognitive over than are you guys are in England. Rachel Handley: So there's that difference of emphasis and approach, but depression is a worldwide problem where we're used to thinking about and hearing about the statistics and figures like one in five, often quoted in terms of what lifetime prevalence is a big burden on the health of the world population. But it's been suggested that even those high figures might be an underestimate. How significant, Steve, is depression as a problem? Steven Hollon: Yeah, I do a undergraduate class. I'll go and do another meeting later on this afternoon where the whole focus of the class is everything we were wrong about a decade ago, and one of the things we were most wrong about is, we've always thought of depression as the single most problem with psychiatric disorders, and it is, but it turns out it's about 4 to 5 times more prevalent than we realised. And our estimates were based on good retrospective epidemiological surveys, the kind of thing we did in the States with the National Comorbidity Study. Ron Kessler, superb epidemiologist, did that but the methodology is to interview a large number of people over the course of a year, and they range in age from their late teens up to the 80s. And when you do that, about once a year, you'll start getting calls from journalists that say, I noticed that people in their 80s have fewer episodes than people in their 20s. Is there an epidemic? No, there's no epidemic. Just people in their 20s remember an episode of their 20s. People in their 80s don't. So it's a memory problem. If you look at the birth cohort studies that follow people from birth on, like the marvellous Dunedin sample that Terrie Moffit and Avshalom Caspi have inherited and followed, where the sample is now in the mid-forties, you get estimates of depression which are at least 3 to 5 times higher than what we get from the retrospective surveys. And the biggest proportion of extra cases that we hadn't realised are single episode patients. We've always assumed that depression was quite common, about, as you say, about one person in five but highly recurrent. Turns out it's much more common than that. The Dunedin sample, over half of those folks have now had at least one episode of depression, but the bulk of them don't go on to have a second. And what it turns out is that, what it looks like is what an evolutionary biologist would call a species typical behaviour. Any one of us could get depressed if something bad enough happens. Now, there's a subset of folks that go on to have multiple episodes. We don't have a good explanation as for why that is. Scott Monroe and Kate Harkness did a terrific pair of articles, 2019, in Psych Review, and then 2022, I think, in Annual Review where they suggested a dual pathway model that some folks hit adolescence at elevated risk which sounded very compelling. I thought they're really onto something. I remember writing very positively about that. But when you check in the distribution of episodes, in the Dunedin sample it's purely linear. Most folks that have an episode only have one, the next largest group of people have two, next larger group of three, et cetera. But there's no bimodality and that were something like intelligence where there are a large number of factors, no one of which counts for much of the variance. You got a nice normal distribution with a small number of people, genetic anomalies, birth, trauma, et cetera, at the low end, get a little bump. We don't get anything like that. Or if you think of gender or height is normally distributed within women, normally distributed in men, but the two together make a bimodal distribution. If there were really some kind of diathesis that accounted for a large number of cases of recurrent depression, you would expect bimodality, and we just don't see that in the data. Rachel Handley: And so when we look at current reports of increasing incidents of depression since COVID, for example, would your perspective be that's more likely to be measurement area error? Or is that just something so bad has happened that we can get depressed from that. Steven Hollon: yeah, I mean, things happen. We had increases during the depression and increases in suicide, usually suicides, a hard index, and more people jumped out of windows in the 1930s than before or after. I do think when bad things happen, more people are going to get depressed, so it wouldn't surprise me if we have an excess, I would be surprised if they go on to become recurrent. Rachel Handley: Okay. So it doesn't necessarily mean in the longer term, we're going to see an increase in of people presenting for therapy, but we don't know. Steven Hollon: We don't know. I'll be curious. My wife's a developmental psychopathologist. And what she would say is that the thing you don't want to do to 12, 13-year-olds is not let them be in classrooms with other 12 and 13 year olds and make them go through social media, feel criticised, et cetera, that's a recipe for generating angst in young adolescents. Rachel Handley: Absolutely. And given this huge prevalence that you're talking about of single episode depression and then these other presentations where people have recurrent depression, when you see a presentation like that, so pervasive across the species, it might lead you to speculate about is something adaptive about this? And when we look at anxiety, for example, it can seem obvious that being alert to threat would have some adaptive functions, perhaps even things like anger, the function around seeking justice or restoring kind of normal social norms. What might be the value of a depressed mood? Steven Hollon: We thank God for first responders, they keep the rest of us alive. But in our ancestral past, if you didn't walk up to the edge of a cliff, you're more likely to live and have offspring than if you did. So anxiety does serve a function. We've never had a problem with that. Pain serves a function, and pain keeps you from doing additional damage to injured tissues. We've never thought about depression as having a functional advantage. Paul Andrews, the evolutionary biologist at McMaster in Canada, has I think really come close to nailing this. The number of good evolutionary biological theories of depression, any one or all of them might be true to greater or lesser extent. The thing I like particularly about, Andrews and Andy Thompson, his colleague, in a paper they published back in 2009 in Psych Review. When I first read it, I thought, hey, these guys, lovely, but they have no idea what they're talking about, they just got it wrong. And over the last decade of arguing with the two of them, I'm now convinced they were more right than I was. The thing I like about that, what they say is that depression evolved because it gets us thinking very hard and long about social, complex social problems. And in our ancestral past, the one thing young primates couldn't afford to do was be thrown out of the troop. If you were, you're going to get picked off by predators. And if you're a young adolescent female, who's probably already been impregnated, it's going to be a double whammy evolutionarily because you and the offspring are going to be lost to posterity. Now the problem with, you can avoid falling off a cliff if you don't walk near the cliff. but if you've offended the elders in the troop, you got to sort out how you're going to deal with that. Now we know, and by the way, let me just say there's a major difference between unipolar depression and depression as it occurs as part of a disorder, the depressions are virtually identical. However, unipolar depression is not only our single most prevalent single psychiatric disorder, and a lot more prevalent than we used to recognise, but it is so high prevalence, modest heritability. It's heritability is about 0. 3 to 0.4, which makes it less heritable than political preference and huge gender distribution from early adolescence on, women about twice as likely to get depressed as men. I suspect it's because they tend to get involved with men, but what do I know? The bipolar disorder, you don't necessarily have to have a depression to get diagnosed with bipolar disorder, although most folks will have depressive episodes as well, but the defining feature is one or more episodes of hypomania or mania. And of course, mania, hypomania are the mirror opposites of clinical depression, virtually all the same symptoms are involved, they just go the opposite direction. But it's highly heritable. 0. 7 to 0. 8. along with the schizophrenias, it's the next most heritable disorders to autism. The gender distribution, there's no split, every bit as common in women as in men. And even though the depressions are virtually identical, you just don't see the swing to hypomania/mania. Now, there's some reason to think that we are sometimes diagnosing people that truly belong in the bipolar spectrum as unipolar if they hadn't had a major manic episode, the individuals who tend to be hypomanic don't regard that as abnormal. I mean, I wouldn't have realised- I've mentioned earlier, I have my own personal history of depression, three bona fide episodes. I always thought of myself as somebody that had a history of unipolar depression. I'm out to dinner one time with colleagues in Amsterdam and they'd invited in Jules Angst, the great Swiss psychiatrist of marvellous longitudinal studies. And I didn't know the guy before, but they were kind enough to invite me to join and we're talking over dinner and I just gotten in that morning and, he mentioned in polite conversation was I concerned about jet lag? I said, well, I don't get jet lag. I just, I get a little speedy. But the rate of speech picks up a little bit, and he asked me a few other questions. He said, you've had depression? I said, yes. He said, well, are you unipolar? I said, yes. He said, no, you're bipolar. You're in the spectrum. Rachel Handley: Wow. It's not necessarily what you expect when you accept a dinner invite. Steven Hollon: Yeah, well, you do when you meet with a Swiss psychiatrist who devote their career to longitudinal research, open for anything. But it's probably true. And I wouldn't want to lose that. I mean, some people take drugs so they can get the sense of great energy, a little bit of grandiosity. And except for occasionally making an inappropriate comment, it's never gotten my way. And I suspect, half of my publications come from getting a buzz on something and 3 days later coming up for air. So we know that Bipolar II is one of the hardest diagnoses to get right. And it turns out if you, as we often do with clinic interviews, you ask the individual himself or herself, they don't see it, to them it’s just normal coincidence. If you ask their significant others, the people that live with them, coworkers, they all recognise it. So it's not hard to diagnose if you ask the people that live with the person, but it's hard to ask the person himself or herself. At any rate, psychotic depression is a problem, but we also are learning now, and a lot of that's coming out of research, people doing at the Social Genetics Institute at the Institute of Psychiatry, one of the things we're learning with these large GWAS studies is that the serious mental illnesses, the schizophrenias and the psychotic affective disorders, particularly, psychotic mania are more closely related genetically than bipolar disorder is to unipolar, or at least as closely as bipolar disorder is to unipolar disorder, and non-psychotic unipolar disorder is at least as closely related to the anxiety disorders. So, the evolutionary biologists are calling for reorganising our nosologic system, so that we're separating out the serious mental illnesses, all of which are highly heritable, low in prevalence, and show no gender disparity, and almost always need to be treated with medications or somatic treatments from the non-psychotic disorders; anxiety, stress, depression, unipolar depression which are modestly heritable, usually have a big gender disparity an, tend to respond at least respond to neuropsychological intervention often with an enduring effect. Rachel Handley: And it sounds like you were saying this might have a difference for how we view the adaptive properties of these different types of presentations. So you were talking about unipolar depression, and I'm on tenterhooks to hear what is it? So, so I've offended the elders, and I've got to solve a social problem. How do I get there? Steven Hollon: Of the several various good evolutionary biological theories of depression, something like conservation withdrawal, which is when things go wrong, you don't want to expend a lot of energy. So you hunker down. it's probably the case because that's older. You find that in organisms that don't have cortexes. So, molluscs show a conservation withdrawal when the environment is not supportive, and it looks for all the world like a depression. One of the things Paul Andrews and colleagues would point out is we have at least three symptoms that revolve around negative affect stress and they are, sickness, starvation and then clinical depression. And in sickness, quotes, depression, energy gets routed away from the cortex, it gets routed away from growth, reproduction. It gets routed away from hedonic pursuits like sex and food and towards the immune system. If you've got an infection, what you got to do is survive the infection so a lot of the energy goes there. If you're starving the energy gets routed to the maintenance of our organs, the brain, the heart, the liver, et cetera, the extremities waste away. If you're thinking about anything, it's only food and if your behaviour changes at all, it's only spend more time foraging, looking for food, it turns down the nucleus accumbens. So again, you lose interest in sex, you don't want to go out on dates, you lose interest in other kinds of things. In clinical depression, the energy goes to the cortex. And it doesn't go to the immune system, it doesn't go to maintenance of vital organs, and it goes to the cortex. And when it goes to the cortex, it does a couple of things. The Raphe nucleus deep in the brain stem is where all of the neurons in the brain that use serotonin as a neurotransmitter have the cell bodies. It's very ancient, probably came in with the mitochondria- God knows how long ago when we had separate organism organallia, and it was probably mitochondria, probably separate or just the blast pharmacist in all organisms. Now they're what convert sugars into energy, that's how we get energy to do things. But serotonin was very closely associated with that. And it looks like serotonin's primary role in the brain, in the body and in the brain, is not so much to be the target for antidepressant medications, which it is. It was to shift energy back and forth between positive hedonic pursuits and negative pursuits, avoiding danger. And any organism has to do two things over the course of the day, it has to get lunch without becoming something else's lunch and our positive affective responses push the former; sex, food, et cetera, things good for the individual, good for the species. And our negative hedonic pursuits push the latter. Jeffrey Gray, who started Oxford and was for years the head of psychology down at the Institute of Psychiatry, really lay out the neurobiology that, probably two decades ago now. And, with dopamine seems to be the primary neurotransmitter driving it. Dopamine is not the “I like it” neurotransmitter, it’s the “I want it” neurotransmitter. And when you pursue things, the dopamine neurons are lighting up. Norepinephrine is the primary neurotransmitter involved in regulating negative affect. If you're going to have a panic attack, it's when the locus coeruleus fires, which is where all the norepinephrine neurons in the brain have their cell bodies. At any rate, when the raphe nucleus fires, it projects to the amygdala, which gets you paying great attention to whatever it is that's distressing to you at the moment. It projects to the hippocampus which activates short term memory, which is energetically expensive, it burns up a lot of energy to think hard about something. It projects to the prefrontal cortex, which makes you resistant to distraction. It projects to the nucleus accumbens, which turns down hedonic pursuits, sex, food, et cetera, and it projects to the hypothalamus, it cuts down activities like growth and reproduction. Basically, when the Raphe Nucleus fires, it makes the brain ruminate. And then it asks itself the question, why in God's name would evolution set something up which makes you ruminate about things? Rachel Handley: Because we hear rumination in therapy and we think that's a bad thing. We don't want to be there. Steven Hollon: We all got it wrong. I spent the last 40 years trying to help patients not ruminate and an evolutionary biologist like Paul Andrews comes up and says no, that's what depression was designed to do. And it's a basic principle of evolutionary biology that any intervention which facilitates a function that an adaptation evolved to serve is preferred over one that doesn't. And it works in the following way, what I think we do with cognitive therapy is we structure people's rumination, so they don't get stuck and any client I've ever worked with gets stuck blaming themselves for their misfortunes. Now, sometimes they've engaged in behaviours which can be trip into the misfortune, sometimes they haven’t, it’s just the piano fell out of the second floor and hit them on the head. But, mostly everybody I've ever worked with is convinced when they come in that either they're unlovable if they're interested in affiliative concerns, or they're incompetent if they're pursuing achievement kinds of concerns or both. And when I first read the dual pathway model by Monroe and Harkness. I thought that seems weird that that's the diathesis. And we have good data that people go into, for example, college with the propensity to blame themselves when things happen or more likely get depressed during their college years. However, with the absence of bimodality, you got to think maybe that's one of the things that gets triggered when you get depressed and not necessarily something that predates the depression. That's one of those mysteries we still have to sort out. But I'm with all of this is Andrews and Thompson's approach, accounts for what goes on in the brain and where the energy goes in a way that no other existing, evolutionary theory does. And on, on that basis, I got to think there, there are too many little factoids that it accounts for it. You just couldn't account for any other way. Rachel Handley: So let me check. I've understood what you've said. So it. We started thinking about what might be adaptive about low mood and that might lead to this kind of prevalence of depression. And you said that the changes that go on in the brain are really well positioning us to focus our attention very closely on the problems, the threats that we're dealing with in the here and now and to resist distraction, to be absolutely able and ready to, in effect not eaten-we want to solve the problem, the threat that's out there, that we're dealing with and you still. Steven Hollon: Exactly, although the threat here isn't getting eaten, it's being ostracised. Rachel Handley: So it's a social problem. It's there. I've offended my elders. I've offended those around me. I don't want to get, become an outcast from the social group. So low mood is really setting us up well to problem solve our social problems, but it gets stuck. It gets hijacked when you think I'm unlovable or unworthy. Steven Hollon: Thats that's what I think. Now, again, I'm still arguing with Paul Andrews about this, but my hunch is in two to three years he will have convinced me. He would say, if you make people sad, just an experimental task, like having them do expressive writing risk happen, they'll start switching into this type two thinking. And there's nothing exotic about the type two thinking. Daniel Kahneman talks about thinking fast versus thinking slow. If you don't want to step on a poisonous snake in the woods (unless you're in Ireland and we don't have to worry about it) there's something squiggling on the ground, you put your foot back before even aware of what you think the dangerous, that's thinking fast, heavily heuristic driven. And there it's having a fire alarm that rings when there's no fire. It's okay to have some false alarms. You don't want to miss a true fire. Depression seems to activate when you get sad, it activates type two thinking, which is slower, requires short term memory.You have to store the stuff in memory, sort out. Could it be this? Could it be that? What can I do about it? And it's energetically expensive. So you don't want to spend your time doing other things that are going to distract you. You don't want to be pursuing other kind of hedonic values. Get your complex social problem solved and then you go on with your life. And if you track the longitudinal work, what Andrews would say is that the first thing that's going to happen when you get sad, it's going to take you into what he calls root causal analysis. What went wrong? What went wrong? What went wrong? Which then feeds relatively logically on to problem solving. What can I do about it? And if you track people across time, across the course of an episode, they go from sadness to root cause analysis, heavy focus on where have I screwed up or what screwed up to the problem solving? What can I do about it? And the problem solving is negatively correlated with subsequent depression. The problem solving brings it down. It looks like evolution built a mechanism which helps you identify and resolve a complex social problem which would have led to ostracism from the truth. The fact that depression, highest incidents, highest levels of onsets of more than half the folks ever get depressed, unipolar depression kicks off in early adolescence and twice as common in women as in men. Rachel Handley: And some folk get stuck there. So it doesn't solve their problem. They get stuck there. Steven Hollon: Some folks, I mean, I'm so used to working only with the people that get stuck, that, I've been really been looking for what the diatheses are. And that doesn't mean there aren't diatheses, certainly, some people have more genetic predispositions than others. Some people have childhood trauma, et cetera, a number of things we know increase the odds for getting depressed down the line but how much of that played into our evolutionary past, ancestral past, who knows. Rachel Handley: So, you've said a lot about where depression may come from, what role it might play in us as a species. We've talked about a bit about vulnerability, what we know about that, you said bad things happen, people get depressed, gender can play a role, and there may be other factors that we as yet don't know that play a role. Once depression is set in motion (we love a great formulation on this podcast) we love to know what keeps it going, what maintains depression. But we don't have boxes or arrows, we love those in CBT, but on the podcast, we have to do this without any boxes or arrows or diagrams. That’s your challenge. Steven Hollon: Yeah, I mean, that's why God made napkins. You got to drop your calls in the office. The, the, how Rachel Handley: I'm getting it. I'm getting a good picture of your dinner parties, drawing diagrams on napkins. Steven Hollon: Well, I show up at family gatherings with slides, really annoys them. But, gee, I think it works almost in the following way, almost nobody in a first episode comes in for treatment unless it's become chronic. So we don't see the bulk of the people that get depressed. And by the way, I don't know what they're doing in ICD now, but in the States, we have an ongoing debate about what do you do with grief reaction. Somebody loses a spouse, losing a child is most depressogenic, it could happen to anybody. And we know what grief is like, Freud in his classic article back in what, ‘17 we published in ’21, to differentiate between mourning and melancholia. He said in mourning, your life is diminished and in melancholia, you see yourself as diminished. And, increasingly, we're not sure that there's a difference between the two, that a loss that you would get in mourning triggers the same underlying mechanisms. But you're still going to have to think your way through that. I remember watching a family member, lose a husband young, with a couple of young kids and watching the grief reaction set in. She had to do a lot of sorting things out. Had to decide how is she going to provide for her children, how is she going to cover their college expenses? Because they were, going to be going from early teen on. She had to navigate once again, the dating role. All kinds of things, problems she didn't have three months earlier. And she had to think about things. So if Andrews and Thompson are right, evolution built a mechanism which almost always is going to help a depression resolve, almost always going to lead you to have to think your way out of whatever the situation is that you're in, that you probably weren't in before something bad happened to you. Now, that's not to say necessarily that they're right, but there's a grief reaction neurobiologically it’s a depression, so why would you separate out. For some reason, the field has always assumed that if you know what the reason is that somebody is depressed, then it's not a depression. And that's just silly. And, what's the saying? If it looks like a duck, if it walks like a duck, if it quacks like a duck, it's a duck. So, once you start bringing that in, then any one of us could have the propensity to get depressed if something bad enough happens. Mercifully, most of us don't have that many bad things happen, but if they do we're going to have multiple episodes. Now, it could well be that people learn the wrong things in the midst of a depressive episode. And I think that's where the treatments come in. Again, I've never worked with anybody that didn't have a propensity to do what, Paul Salkovskis would say, their theory A is something wrong with me. And an alternative theory B is usually, well, maybe you're using the wrong strategies. So what we try to do in cognitive therapy is to pit one against the other. We'll start with what their theory is walking in the door, I'm unlovable. I'm inadequate, whatever that may be. Get them to do self-monitoring, where they monitor their experience over a couple of days or weeks, getting them to start paying careful attention to what's going through their head when the affect is triggered. And by the way, it’s the lovely book that you held up, thank you, in the very beginning, is Cognitive Therapy for Depression, but you treat the person, patient that walks through the door. And, when we do one of our trials with people who meet criterion for major depression, two thirds of them meet criterion for other things, anxiety disorders, stress disorders, about a third of them would meet criterion for substance use disorders, so whatever you're going to do, you have to be a generalist, you have to meet where they are. And one of the other things that comes out of evolutionary biology, they would say that Jerome Wakefield, the, social worker who has been a major critic of existing diagnostic categories, Wakefield would say for something to be a disease must meet two criteria. It has to represent a dysfunction in an evolved adaptation, something has to have broken down and it has to cause functional impairment. And an example he would give of the latter is a very small percentage of people are born with the hearts on the right side of their body. But they don't do anything to them. They go to their lives, same kind of life expectancy, et cetera. So there is a breakdown of the mechanisms wherever the in utero, the various organs are shown where to go and where to develop. For them it develops on the wrong side but doesn't affect their lives at all. So it, meets the first criteria and it's a breakdown and evolved adaptation, but it doesn't cause dysfunction. On the other hand, something like a brief reaction, may not be a breakdown and evolved adaptation be exactly what the brain evolved to do, which is to think long and hard about a problem. If you've got a problem, you have to deal with that you didn't have to deal with before. The reason I go there is the other thing that for years as a psychologist, I'd say, well my colleagues up in psychiatry want to talk about diseases and most folks get depressed, they don't have a disease. What they have is a disorder. From an evolutionary biological perspective, it's also not a disorder. It's very orderly. And anytime, there, what a evolution biologist would say is that, our adaptations evolved to generate a whole body response given the different threats that we're exposed to. If there is something dangerous rustling in the bushes, you want to experience anxiety. You want your physiology to get turned up, sympathetic nervous system to fire up so you can run away fast, and your behavioural impulse is going to be to flee. The cognitions are, I'm in danger. I'm in danger. I'm in danger. All orderly. It's not disorder. It's orderly and it's an orderly adaptation. If you are challenged, particularly interspecies challenged, the affect's probably going to be anger. They shouldn't do this, et cetera, et cetera. The physiology again is going to get elevated. You've got sympathetic arousal so you can fight, if that's your natural inclination, the behavioural impulse is going to be to attack and the cognition is going to be they have no right doing that to me. How dare they. It's orderly. In depression, the affect is sadness, physiology gets turned down, it's more parasympathetic than sympathetic. You get this whole dropping feeling in the pit of your stomach, and the behavioural impulse is to do nothing except sit and think. And the cognition is going to be, what did I do wrong? What did I do wrong? What did I do wrong? Or at least what went wrong? Again, orderly. And the thing that evolutionary biology is going on is all of our negative affects are unpleasant to experience, but they all organise a whole body response that in our evolutionary past was probably the optimal response for whatever it was, wherever the different threat was that we had to deal with at the moment. Now, individuals differ in the way they interpret different situations, which means they're going to generate different whole-body responses, often to the same situation. My wife, absolutely lovely, but East Coast ethnic and her whole family has to and does spend a lot of time worrying about things, which is good because I never do it. It balances off the relationship nicely. But if we get bad news, she'll go oh, that's awful. And I’ll go, that's inconvenient. Just different. Her autonomic nervous system gets triggered faster than mine does, which is beneficial in some respects. And, God knows, I certainly have done stupid things like said, gunfire, let's go see what it is. It just, some folks can live longer given that kind of thing. But if different individuals interpret the same situation differently, then we're going to trigger different whole-body responses. But it's our evolutionary process that gave us the different whole-body responses and virtually nobody can't feel anxiety, anger, grief, depression, et cetera, they just sometimes do it in response to different kinds of things. One of the first things I'll try to do with any client in the first session is go to that marvellous circle diagram, that Chris Padesky and Kathleen Mooney came up with. They call it the five-factor model, which has five factors. It's the original ABC model, antecedent, events, beliefs, and that the consequences of the behaviour are affected. They expanded it they put the environment out and then they have a circle which is the organism, it’s classic without really realising its the classic SOR behavioural, learning model. And you've got the environment, things happen. And then within the organism, you're going to feel, you're going to have physiological reaction, have behavioural impulses, and you're going to have cognitions. And what I would say as a cognitive theorist is the cognition drives the others at what's determined, what you're going to get and what cognition you have may be determined by your prior life experience, maybe somewhat by temperament, et cetera, but it all was laid down by evolution. They're adaptive processes that left to run their course in the millennials before we had therapists or medications, we had nothing else. And one thing we know about depression is they almost always go away, we have spontaneous remission, even if you don't get treated depression is going to resolve. I don't know what they're doing in England now but I know in the States, 90 percent of the people who are clinically depressed get medicated and they get medicated by the primary care physician, and primary care physicians are marvellous. They have to worry about 80 different things, 40 of which will kill you. Depression isn’t one of them, but if you mentioned being depressed or anxious they’ll put you on an SSRI because they're relatively safe. The problem with the antidepressant medications is they anesthetise the distress so the facilitate the function that depression or anxiety or anger revolved to facilitate. Rachel Handley: So just stepping back slightly, we started with a thinking about a maintenance model of depression. And it sounds like what you were saying is loss can happen to all of us. Sadness happens to all of us, but if someone has a particular set of beliefs, thoughts, ways of interpreting the world habitually, like that's awful rather than that's inconvenient, or that's personally this sense that there's something wrong with me, what's happened means there's something wrong with me. This will trigger this kind of evolutionary, instilled physiological whole-body response. It leads to kind of natural behavioural responses, of withdrawal and down regulating our kind of impulses for behaviour Steven Hollon: Well, it does all that until you sort it out. And once you decide what you're going to do, then it, and again, it's, it, follows a sequence, which ends up generating an action plan, which then if you carry out, it resolves the depression. Rachel Handley: So, if all works well, it resolves, and we move on. But we know that when we do see people for psychological therapy, when we are treating them that actually we tend to see them when they're stuck, when they're in that kind of disordered place that you've spoken about when its functionally not helpful for them anymore. Steven Hollon: We tend to see them when they're stuck. And the stuck is almost always is something deeply wrong with me. And, again, back to Paul Salkovskis and that brilliant observation about Theory A, Theory B, which I never had heard about until I started working with folks in IoP, they taught it to me. Theory A is almost always defective in some way, usually unlovable or incompetent, depending on what you most want in your life or both. And Theory B is almost, well, maybe you're going about it the wrong way. And to give an example. I had a client I worked for way, way back when in Minnesota. I talk about him in the, in the revision of the manual. He was a sculptor by training, he was teaching at a small community arts college. Their entire art department, I think three people, got retrenched during the first Gulf crisis. And now three years later, he's working as a handyman on a condominium complex. Hates it. Hates it. Hates it. Think what he has is a reality-based depression. How could he not be depressed? A sculptor by training, he's doing a blue collar job. He's getting paid more than he was as a low grade academic but as far as he's concerned, that's a terrible, awful thing that's happened to him. The one thing he hasn't done in three years is apply for another job in academia. And you ask him, how come? He said, well, I start to think about it and then I get overwhelmed. So, he'll start to take the steps, what he has to do if he wants that kind of job, is to apply. They're not going to come find him at his home, but he has to apply. So, what we did is laid out the notion, his notion is he's not doing that because he is inadequate, he's incompetent. And the alternative, coming off of Paul Salkovskis is just you choosing the wrong strategies, which is, when you go out in the garage and try to do everything all at once in one evening, you get overwhelmed, and you don't start. So, how about we take the large task and break down it into steps for me, which he did. He knew I didn't know. He broke it into a half dozen steps each night to go out and do one. And if you don't finish first time to come back and finish the next night. Within three weeks, he had a portfolio together. That's how sculptors get their jobs. And he was mailing it out to places. So, I mean, it's not rocket science. It's just taking a big task, break it down into smaller steps. That's the behavioural component, but in the process, we would differ from a more pure behavioural therapist is we don't only do that, we get him testing his beliefs. His belief was it's my confidence; it’s gotten in the way, the alternative hypothesis is you’re choosing the wrong strategies. Not repeating his theory A, something deeply wrong with me, is theory B which is I'm going about it all wrong so let me try something different. And it worked out better for him. Rachel Handley: So the principle underpinning the theory is that the cognitions, the thoughts, the referential beliefs are the main obstacle to him being able to effectively problem solve, break that down. Steven Hollon: That's right. Yep. The main obstacle, I think, and that's why Tim Beck called it cognitive therapy and not cognitive behaviour therapy, as far as he was concerned, that was the primary mechanism that was going on there. And I think, somebody like David Clark would talk about panic disorder, the main issue is you have these catastrophic cognitions. You interpret benign physical sensations or psychological sensations catastrophically. And that's the real issue. There are things you can do about that behaviour that help move the process along. I think Anke with stress disorders would talk about the failure to recognise that that was then, this ain't then, this is different-and getting past that focus that, that belief right at the moment is the kind of thing. So always we would see the cognition at the core but often use behavioural strategies to go after the accuracy of those beliefs. David and Anke don't bother with thought records at all. And they get people moving very rapidly into behavioural experiments, going into stores on the, on you guys have what high streets or something where you have shopping districts, with a rouge on their face or obvious stains in their underarms, that kind of thing. Or I'll go have people going back to the park where the rape occurred that to regain their lives. We'll make a lot more use of thought records with somebody who's clinically depressed because so much, well, I think so much of what revolves in the depression is the self-referential, the blaming of the self. And for that, you want to get people out testing things, testing their beliefs, et cetera, in real world experiences. But a lot of that stuff, you got to go back and trace down what it meant to them that it did work. Rachel Handley: So you have to take some time identifying, seeing the patterns, the habits, the… Steven Hollon: I could be wrong. Somebody's come, come along from Oxford that's going to blow that out of the water and show you, you can do all this stuff, wrap it up in two, in 20 minutes. But, so far I've done this for 50 years, I'm probably not going to be the one to do that. Rachel Handley: But it sounds like an important part about the point about the terminology. So it's not that cognitive therapy isn't incorporating behavioural techniques at all. It's just that where behavioural techniques are incorporated as they frequently are, it's in service of changing the cognitions Steven Hollon: Yeah to test the accuracy of the cognition. And this goes way back to Tim Beck, and he picked up on this back in the early sixties. Even if the primary problem is, what you believe the best way to test it out in the real world is to put it against an alternative and let the data decide. Rachel Handley: So this seems like a good point to take a break to allow you to ruminate, hopefully in a healthy way, on part one. Those of you with extra stamina may wish to dive straight into part two where we get to work discussing the application of cognitive therapy of depression to the problems people present with, both more straightforward and much more complex. And Steve even has a go at planning a brief hypothetical invention for the president of the United States. Thanks so much for listening, and as always, till next time, look after yourselves and look after each other. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    
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  • “I’m forever bursting bubbles (or perhaps not)…” Kim Wright and Tom Richardson on treating Bipolar Disorder
    In this episode of Let’s Talk About CBT- Practice Matters, Rachel Handley talks to two expert guests – Professor Kim Wright from the University of Exeter and Associate Professor Tom Richardson from the University of Southampton – about bipolar disorder and the role of CBT in supporting people with this diagnosis. Tom and Kim share their extensive clinical and research experience, alongside insights from Tom’s own lived experience of bipolar disorder. They discuss common myths, the importance of timely and accurate diagnosis, and how CBT can support people with bipolar in a meaningful and collaborative way. They explore what CBT for bipolar looks like in practice, including work on relapse prevention, mood stabilisation, routine regulation and addressing beliefs about mania. The conversation also covers important systemic issues such as gaps in service provision, barriers to access and the need for more widespread training and implementation. This episode is released to mark World Bipolar Day and aims to raise awareness and improve understanding of this often misunderstood condition. Resources & Further Learning: ·        Richardson, T. (Eds). Psychological Therapies for Bipolar Disorder: Evidence-Based and Emerging Techniques. Spinger-Nature, 2024. ·        Bipolar UK Commission ·        Find out more about Kim Wright’s research and publications ·        Find out more about Tom Richardson’s research and publications Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [email protected] Subscribe and leave a review – and don’t forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Welcome to. Let's talk about CBT Practice Matters, the BABCP podcast for therapists using cognitive behavioural therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today I'm delighted to be joined by not one, but two expert guests, my wonderful friend Kim Wright, Professor of Clinical Psychology at the University of Exeter, and the equally wonderful Tom Richardson, Associate Professor of Clinical Psychology and CBT at the University of Southampton. Both of our illustrious guests specialise in researching, treating, teaching, and training others in psychosocial interventions for bipolar disorder. Welcome guys. Tom: Thanks for having us. Rachel: I know you've both been working in this field of bipolar for many years. Kim, when I first met you, you were doing a PhD in bipolar, even before embarking on your doctorate in clinical psychology. And Tom, I know you have personal as well as professional reasons to be so committed, and passionate about the area. Can you tell us a little bit about your pathways into this work? Kim: Yeah. Hello Rachel. It's really good to be here. So, I, started out quite a long time ago, when it was possible to finish your psychology degree and go straight into a research associate job and I was very fortunate to be able to do that and work with Dominic Lamb on his trial of CBT for people with bipolar, for relapse prevention. And that is at the, or was at, Kings College London and it was one of the early CBT trials in the area and it was really exciting to be involved in it and as part of that, again, this is a bygone era, it was possible to do a part-time PhD that was heavily subsidised for members of staff of the institution. So I did my PhD part-time with Dominic alongside my role, and that gave me the opportunity to meet hundreds of people with bipolar disorder and hear about their experiences. And then, after I finished, I did clinical psychology training and then worked in a community mental health team for a bit. And then I had a really wonderful opportunity to join the clinical research group at the University of Exter where I am now. And back then it was led by Willem Kuyken and Ed Watkins, who work in the area of depression. And they liked the idea of broadening out the team to include a focus on bipolar. So that was a great opportunity for me to return back to research in the area of bipolar and also to work in the research clinic that we set up in the university not long after. Rachel: What a brilliant opportunity to work with such amazing people, but also to be in there from the ground up, working on that first CBT trial in the area. Really exciting. How about you, Tom? Tom: Yeah. Well, as you said, my research interests really has come a lot from my own experiences because I have Bipolar disorder type I. I haven't always been completely open about that. It's taken a few years of qualified life for me to feel comfortable with that, but yeah, I ended up having a manic episode just after my A levels, just before I started my degree, my undergraduate degree. I ended up in a hospital with a manic episode, so that got me interested in it. And then, when I was doing my undergraduate degree, actually I started doing a little bit, I started doing some stuff for kind of student journals and my thesis was actually about hypomania and how it relates to impulsivity and risk taking in the general population. So I actually became hypomanic about my dissertation, about hypomania. So, and then I was working as a research assistant on sort of computer-based CBT at the University of Bath with children. But I did a little bit of stuff, a few bits of research and kind of papers around bipolar disorder, around like letters to the editor and reviews and that kind of thing. And then when I started my doctorate here in 2010, and that's when I started to get my kind of first real clinical experience, my first placement, I worked with a couple of people with bipolar disorder. And then, I was working in the NHS in Portsmouth community mental health teams for eight years. And that was a whole range of problems, but I did a lot of bipolar work there. I set up and ran a bipolar group, which was, which I really love doing. So it's gone from there. And then I joined the university in 2021, and this is a big part of my research here is about psychological therapies for bipolar. So influenced by my own experiences a lot of the time, as well as my service users. Rachel: And I know that's naturally and rightly a very personal choice to share that information about your own mental health, but incredibly helpful, I think, for other mental health professionals as well as I'm sure your research to de-stigmatise that area and to be able to think about it from the inside out. Tom: Thank you. Rachel: We've recorded a number of podcasts recently on unipolar depression, and in fact, we've got a whole series of podcasts on depression coming out. This will probably be the first one because we've got World Bipolar Day coming up, but those conversations really underlined to me how common unipolar depression is. And our listeners will be not only aware of that, the massive numbers of people suffering from depression, but also probably seeing them in their practice’s day in, day out. But bipolar is perhaps a little less well recognised and understood. So, can we start with some of the basics? How might we recognise bipolar disorder or bipolar spectrum disorders outside of sort of dramatic portrayals, like the likes of Claire Danes on Homeland? Kim: Yeah, so you're absolutely right. Bipolar is quite a lot less common than unipolar depression. I would say if you're seeing someone with recurrent depression and they report periods of consistently elated or irritable mood that go on for, say around four days or so, as well as some heightened energy and activation that's pretty persistent over that period, you could ask them a bit more about that time. A key thing is often sleep, people often talk about dramatically reduced need for sleep, but still feeling rested. They might also talk about that their mind's racing, that they're talking a lot more than normal and importantly, if they're around other people, noticing that they're different at those times and there isn't another obvious explanation like stimulating drugs or an overactive thyroid, for example. And I think it can be a tricky one because I think a lot of clinicians are quite reluctant to pursue diagnosis for the, supposedly the milder, subtypes of bipolar. But there is this concern in the prescribing community about the potential for SSRI drugs, antidepressants, to increase vulnerability to mania. So it can be important for people to know if they do have that tendency to periods of hypomania, in terms of treatment choice, in medication. Rachel: Why? Why do you think clinicians are reluctant to pursue those diagnosis? What do you think is driving that? Kim: I think it's partly to do with maybe concerns about people getting a stigmatising diagnosis, concerns about people being, particularly young people, being prescribed what are often seen as quite heavy medications with a considerable side effect profile. And also, the difficulty that there can be if people have quite a rapid cycling, mild or subtype of bipolar with distinguishing that from other potential explanations. So that can make people, some clinicians, maybe more reluctant to diagnose. Tom: I think it's also worth saying that it also just gets missed a lot of the time. I was part of the Bipolar UK Commission, so we wrote some reports as part of that and that one of the key, really shocking findings was it was nine and a half years average to diagnosis. And nine and a half years after you'd been in touch with a mental health professional. Most people are originally diagnosed with unipolar depression, they're diagnosed with a depressive episode, but the hypomanic/manic side often gets missed because you're not likely to go and get help for that unless it's really severe. And then you might end up in hospital or contact with criminal justice or something horrible like that. But actually, a lot of the time people won't go and get help. So it does get missed for a long time because these episodes of hypomania/mania, they go on for a long time, they go on for weeks. That's an important distinction, we're not talking about daily ups and downs here. These go on for a long time, but they still don't go on as long as depression, people are depressed for months, people are hypomanic for a few weeks. So it's very easy to get missed even if you're under a mental health team. Rachel: And Tom, Kim mentioned stigma and that being a barrier sometimes from a professional's point of view to diagnosing these problems. Do people suffering from these issues want diagnosis? What do you think about the whole issue of stigma for people who are presenting in services? Tom: And I know there, there might be some therapists and clinical psychologists who, maybe don't agree perhaps with the term, but actually the research we did with Bipolar UK I think it was 85%, 87% that they found the diagnosis helpful. So we need to listen to that and we need to respect that. Yes, some people did say it increased feelings of stigma, but that was a real minority. And actually, other people were saying positive things like it got me the help I needed, it got me the medication, and it gave me an understanding from my experiences. Maybe there's a small risk of stigma, but I think it's improving. I think the awareness about bipolar disorder in the general public is better than it was a few years ago. And actually what the Bipolar UK Commission found people saying it, it helped make sense of my experiences, I think that's counteracting shame and internal stigma about this because the consequences of bipolar, how people act when they're manic in particular, spending money and changes in sexual behaviour, there's a lot of shame and stigma that can come with that internally, people being very hard on themself and that fuelling depression. So actually people having an understanding and knowing that, and if they're not alone with this and this is part of a condition, can be really helpful. Rachel: I think at risk of finding very circular, diagnoses in general are helpful if they're helpful. So if they help people understand and also help them access appropriate help and treatment for the issues they're facing, which we will come on to, won't we? Is there anything that’s helpful for people to know about distinctions between subtypes of bipolar disorder or a spectrum of bipolar disorders? Tom: Yeah, so there's the two main types are Bipolar I and Bipolar II disorder. Now this wasn't always made as a distinction and a lot of people who are listening to this with bipolar might not be aware if they are Bipolar I or Bipolar II, a letter from a doctor might just say Bipolar Affective Disorder. They might not be clear. The main difference is mania versus hypomania. So Bipolar I, which is probably a little bit less common than Bipolar II. It's the more severe mania, full mania where these changes in energy and impulsivity really do get quite extreme and it causes all sorts of problems, people might end up in hospital. So Bipolar I is the more severe mania. Usually with depression, not always, there are some people who just get manic, but most of the time it's depression as well. Bipolar II tends to be sort of more severe depression and then hypomania, which is less severe than full mania, won't cause as many problems, you're not likely to go into hospital with hypomania, but it still causes problems. I think that's important to say, I think hypomania can be dismissed as, oh, it doesn't cause any problems, but it does, and you don't meet the criteria for a hypomanic episode. So that's the main distinction, is mania versus hypomania. Sometimes people may get a diagnosis of cyclothymia, which is where people have these sort of milder hypomanic episodes and depression episodes that don't quite tick those boxes. So I'd consider them people who are high risk for bipolar disorder. Rachel: Okay. That's really helpful. I wonder if there are any other, or any myths about bipolar and how it presents or is often understood that you'd like to bust that might be barriers to clinicians understanding or engaging well with people in this area. Kim: I think a big one for me is the portrayal of the high periods as being times of extreme happiness or extreme positive feelings. Whilst they can be for many people, one of the kind of key symptoms of mania can be irritability rather than a kind of happy, high mood. And that can mean that it can be missed because it's the person isn't saying, wow, I feel really joyful and elated. It's more like this huge level of frustration often that things aren't happening quick enough, that people are getting in the way, the world isn't letting things evolve and goals to be met as quickly as the person might like. And also, even if people do start out feeling quite high and elated for some people, that it can become quite unpleasant. People talk about feeling I'm overactivated. I'm not even sure I really want to be, but there's nothing I can do to put the brakes on. Yeah, so that's one myth I would want to bust. Another one would be that some, and this is really important, that there can be a portrayal in the media that someone with bipolar is always up or down, when in fact lots of people with bipolar have very long periods of being feeling pretty stable, being well, and only occasional episodes. Rachel: Yeah. I'm reminded of a recurrent dream. You know, we all have these recurrent anxiety dreams from time to time. One of mine is being in a car and not being able to put the brakes on. When you were talking about that feeling of just speeding up and not being able to stop, that's what that reminded me of and that horrible feeling of being out of control. Kim: Yeah. Tom: I agree with Kim. It's not all pleasant when people are manic people, it can feel very unpleasant, it can feel very distressing, out of control. I think a big one for me is, as I suggested a little bit earlier, a big misunderstanding is that this is daily ups and downs, which might be seen more with something more emotional sort of dysregulation. And when people are manic, they can have this dysregulation where the moods are quite up and down. But these episodes we're talking about are like weeks at a time. We're not talking about it changes one day to the next. We're talking about your hypomanic for a few weeks, and like Kim said, then you can be stable for a long time and then you might have an episode of depression that goes on for kind of a couple of months. So that's a really important distinction. Rachel: Brilliant. Thank you so much for, enlightening us in those areas. What's the place then for psychological treatment with bipolar disorder? I guess we hear a lot about the biological vulnerabilities to bipolar disorder, or there's a sense that this is something that's genetic or biologically driven and I'm sure we'll talk more about that. Is it a presentation that really requires primarily or exclusively a pharmacological intervention, or does that differ depending on what stage you're at in terms or phase you're at in terms of the symptoms or you're experiencing. Kim: So you're right, pharmacological treatment has historically been the main treatment offered to people with bipolar and in the NICE guidelines there are certainly plenty of recommendations about pharmacological treatment and there are differences depending on the phase of bipolar, but psychological therapies are also recommended and those include CBT. And they're recommended really for two main aspects; so one is for relapse prevention and the other is for acute bipolar depression, at least within the NICE guidelines. I think it's really important to say that unlike maybe with some other conditions, we don't have much in the way of trials of psychological therapy without medication compared to medication. Instead, it's usually psychological therapy in addition to medication or usual care compared to usual care. So the evidence base for psychological therapy as an alternative to medication is not well developed. However, what I would say is, I would hate to see a situation where somebody who can't take medication for bipolar, or chooses not to, is denied psychological therapy because there are just really good reasons to expect it will be potentially really helpful for people. So I would want to see that being an offer to people, who can't or don't want to take medication. Tom: I think a lot of people might underestimate just how effective psychological therapies can be for bipolar. The biggest meta-analysis that's been done, it showed that CBT, group-based psychoeducation, which is often very sort of CBT informed and family interventions, family therapy, nearly halve the risk of relapse, Rachel: Wow. Tom: Which is really impressive. My take on the kind of literature so far is that if you add in medications like lithium, it halves your risk of relapse and then you add therapy on top, it halves the risk again. Which is pretty huge really. It really is. And I think that there, there's sometimes an issue about, maybe there's a little bit of, it's not as clear how much it reduces acute manic symptoms, but I think the evidence suggests maybe it does. And the same with acute depression symptoms. I mean, it is hard to do therapy with someone if they are really acutely manic and really acutely unwell. But actually, the evidence does say, well, it still might reduce kind of manic symptoms. So yeah, there's sometimes an issue about when you do it and what the motivation is cause it's really good for relapse prevention work. Sometimes I personally think that actually working with someone when they're quite stable is a good time to work with them. But there's, you've got to be careful of motivation because if someone's completely stable in mood, why would they want to engage in therapy? Trying to work with someone on a relapse prevention focus can be really useful time. And often people come to therapy after an acute manic episode, for example, and they're trying to pick up the pieces, they've been in hospital for a couple of weeks and they're trying to make sense of what happened and recover and move forward to their life, and that can be a really important time for therapy as well. Rachel: So it sounds like there's really good evidence about this additive effect, about this relapse prevention, perhaps better times when you can do this, where maybe some of the good times to do it where people are less motivated, but perhaps could be really helpful. Do you think there's ever a time ahead where we might have a trial where it's psychological therapy versus medication? Or is that, would that be unethical given the… Tom: I mean, we were talking about this Kim, weren't we? And we were talking about whether you could look back at the trials that had been done because maybe some people weren't on medication. I mean, I think it's been done with psychosis, hasn't it? I think Anthony Morrison did a trial for people who declined to take medication. I think, that would be an ethical way to do it, is you, the people who do decide that they don't want kind of medication, But I, yeah, I suspect it'd be quite hard to find people who weren't taking medication cause that usually is the treatment, the first treatment, and that's not what NICE guidelines say. NICE guidelines say that medication should be given an important weight as well. But yeah. Rachel: Interesting, and perhaps maybe there is that group that you said, Kim, who people who don't want to take medication, that might be where some of this evidence comes from. Kim: And certainly people do ask me that sometimes, is there, are there studies of psychological therapies for people who choose not to or can't tolerate medication? So I think that there is demand out there to know the answer to that question. Rachel: And it's clear that psychological therapy, therefore, is very helpful, can be very helpful. How easy is it for people to get access to the evidence-based treatments that there are currently, and are there any particular barriers that people face? Tom: So NICE guidelines are pretty clear that it should be offered in secondary and primary care but unfortunately the access isn't as good as it should be. So Bipolar UK Commission, again, we found, so 69% have been referred for therapy on the NHS and that might sound okay, but I suspect a hundred percent of them would've been offered medication on the NHS. Only one in five had been offered a group-based psychoeducation intervention, which are very evidence-based and very kind of cost-effective to run and very helpful for the individuals. What's more shocking is that 29% had never been offered therapy on the NHS, and about a quarter had been told they'd have to pay for it privately. Rachel: Wow. Tom: About a quarter had been specifically been told you can't get therapy on the NHS and up to half of people have had to pay for their own therapy at some point. So it, it definitely could be better. Now, I think with the positive side is that health education in England has put a lot of money into training for bipolar, and that's part of my role here is working on the CBT diploma. The Department of Health has been pushing training for CBT for personality presentation, CBT for psychosis, CBT, for bipolar. So, we are getting more and more people trained in this, which is great, so I do hope it will improve, but it is hard and myself and Kim have been looking at for NHS Talking Therapies, formally IAPT, we've just had a paper accepted about what the rules, what the guidelines are, what the kind of policies are about working with people with bipolar within these services because traditionally, officially you don't work with bipolar per se, but you can work with anxiety disorders, for example, or PTSD trauma work within these services. And one paper we did, we found that 33. 0% of people attending one IAPT service potentially had bipolar disorder that was undiagnosed. So there's a huge kind of iceberg of people who aren't diagnosed. So there isn't as good access as there should be. I mean, there is a lot of really great work going on there, there are more people being trained in CBT, which is great, but access to it is difficult. And I think it does vary. That's another thing unfortunately, that we showed with the Bipolar Commission is that there are, it's a bit of a postcode lottery. There are some services, there are a few specialist bipolar services, but then there are other services where you get you are in a mental health team with a lot of other people, and I think the reason people with bipolar can get missed and not get off with therapy is that because they can stay stable for a long period of time. That's one of the key findings we found in the Bipolar Commission is episodic care, which is, as well as just not being the clinically right thing to do. It's also a false economy where don't give people a lot of input and then they relapse and they're in hospital for two weeks and then it's, well, you're okay now, so we'll discharge you. Rachel: And from various insights into Talking Therapy services, I imagine that those sort of time pressures can operate in different ways on the problems that you've raised. So even a good thorough diagnostic assessment and with a good history taking, sometimes it doesn't feel like there's time for that when you've only got so many sessions and asking these questions. But then there's also the rush to get people out the other end, isn't there? Kim: And I think there's three pieces to think about in terms of this, the access question. One is, do we have the evidence-based protocols? Which for bipolar we do. Do we have the workforce? And as Tom said, there've been quite a lot of stride in that direction. But the third piece is the one we've been alluding to and just mentioned around NHS Talking Therapies is, do we have the place, the services in which these therapies would be delivered And at the moment, NHS Talking Therapies aren't really set up to deliver therapies for people with bipolar, and secondary care would be the place. But the barrier to getting or the threshold to entering secondary care where you can access these therapies is very high in a lot of areas. And so we're left with a gap and an absence of psychological therapies really often in that gap. And so I think that third piece for me is the piece that really needs attention. It's all very well to have the protocols and the workforce, but you need a place where the patients can come into contact with those two things easily. Rachel: Do you have a sense of, and this is a big question to ask you, Kim, but do you or Tom, do you have a sense of where that place might be or what might work better? Kim: I mean, I think there are different ways to address this. There are different models that could be used, but I suppose there's something about seeing psychological therapies as an important treatment that shouldn't be behind too many barriers. I think that's one of the things NHS Talking Therapies have done really well. They've put psychological therapies at the front and they're relatively easy for people to access, even if there can be a wait and we don't really have that situation for people with bipolar, although different parts of the country are trying different models of addressing this. For example, having teams that sit in between primary and secondary care or more reach down from secondary care or more reach up from primary care. Tom: I think there's often a little bit of a change in mindset that is needed within services. Because, I mean, firstly, I think I'll just say that CBT for bipolar disorder is easily 10 to 15 years behind where CBT for psychosis is. And I think as a result, I've had people kind of saying, oh, I'm used to referring for CBT for psychosis, but I haven't really thought about it for bipolar disorder, which is slightly infuriating, but I do think it, people aren't aware of the psychological mechanisms, a lot of mental health professionals don't know about CBT, and so people aren't referred. And so it it's that combined with people are relatively stable for a long period of time, so maybe they're not ringing up and asking for lots of help so they can just get left to their own devices. So there is something about a change in mindset needed that, a lot of men's health professionals and service users really just think like, all I can do is take medication. And we really need to think about, well, there's more than that. Medication's really important, but there's a lot more to living well with bipolar than that. And yeah, these two kind of misconceptions that me and Kim have been talking about, which seem to be polar opposite, but people seem to buy into them. On the one hand, as I kind of said before, you are stable, you don't need therapy. But then also people can have this mindset that, well, someone's unwell now so they can't engage in therapy. You have it both ways where I've heard it. Yeah, you can't, you are too stable or you're too unwell, I've heard both. I have Rachel: And when you say 10 to 15 years behind CBT for psychosis, Tom, is that in terms of evidence-based research or is that in terms of knowledge gaps and implementation? Tom: Everything. I think, to be honest, I think, I mean certainly for the kind of the evidence base, like if you think about how many different models we have for psychosis and really big trials, we're just not, we're just not there with bipolar disorder. There's not as many trials, there's not as many people researching it as there are in psychological therapies for psychosis. In terms of actual kind of implementation in the real world, again, I think it's just CBT for psychosis is very well established, we have EIP services in the UK, early intervention in psychosis. So, it's just much more embedded into the culture of psychosis work that CBT is referred for. And I just don't see that being as embedded for bipolar-yet. We're working on it. This is part of it, right? Rachel: Well, and it makes your work all the more important. So Tom, you said a little bit about your experience, your journey into bipolar. I wonder, if there is a typical, how does bipolar disorder develop for people and typically who suffers from bipolar disorder? Tom: Yeah. So bipolar affects everyone. I mean, there are some research about differences in terms of different countries and that maybe more kind of western societies like here and the USA might have a slightly higher prevalence than some other countries, but it does affect everyone. Prevalence, gender differences, there's not that much way in the gender differences or ethnicity, but we know that, for example, and this makes my blood boil, analysis of South London, showed that black service users were less likely to be offered CBT. We know it seems to be a little bit more prevalent in younger people, and it does tend to peak in kind of late adolescents, early, early twenties. How it develops, so in terms of risk factors, and again, there is a role of genetics, I think, and there's various research about how it might run in families to an extent. There's not like a bipolar gene, but there might be this risk and there might be something to do with the brain and the limbic system, how it processes emotions. But there's other risk factors as well, substance use is, there's one paper recently that found very heavy cannabis use in adolescence increases risk. But there's a lot of big role of trauma. We know that parental loss is quite common, parental loss in childhood, bullying and all sorts of childhood abuse. But emotional abuse in particular, emotional abuse is four times more likely in people with bipolar disorder. So I think it's a combination of risk factors. They're never just one thing. There's often a combination of kind of, yeah, I always think of it like the nature and the nurture, stress, vulnerability, people might be vulnerable because of family history, a difficult childhood, et cetera. And then stresses, so life events are often a real trigger. There's evidence that stressful life events, negative life events can lead to depression. But also, a uniquely rubbish thing about being bipolar is positive, good life events can also make you manic, good things happening, getting a promotion, et cetera. Rachel: That is highly disheartening, I would imagine, to realise that positive things can affect you negatively. Tom: Yeah, it is. I mean, for me personally, there have been times where I'm going, oh, I wish I didn't keep getting good news about papers published and stuff because it fuels the mania. Yeah. Rachel: You need to underachieve. Tom: Wow. Well that relates to another thing about high standards and perfectionism, which is some of the stuff I've been researching about bipolar, because when you say you need to underachieve, there's part of me, core beliefs that goes, oh, I don't like that. Rachel: Yeah. I know- and you won't be the only academic who feels that way. I am sure. I know that you've mentioned, previously Kim, other sort of biological systems that might be coming into play. I'm really interested in what Tom was saying about the limbic system. Is there more to say about those pieces interacting in the onset and development of Bipolar I. Kim: Yeah, so I think a couple of these sort of biobehavioural models that have been looked at in the literature over the last few decades, have been particularly helpful for me to have in mind as a CBT therapist. So one of those is about circadian rhythm dysregulation, and this idea that in people who have a tendency towards bipolar episodes, the circadian system is somehow oversensitive or prone to dysregulation, which means that the system that's regulating the secretion of various hormones on a 24 hour cycle, might get thrown out. And when it gets thrown out, it can lead to an escalation into an episode. And the sort of things that might throw that out would be big changes to your routine, like taking a long-haul flight, for example. And there's quite a lot of circumstantial evidence that this circadian system is implicated in bipolar risk, at least for some people. And it chimes really well with research around sleep disruption as being a kind of a risk factor for relapse into a manic episode in particular. And also what lots of people say, I mean, when I talk to people about early warning signs of mania, sleep is there so often, sleep disruption and disturbance, not just as a sign but also as a kind of cause. So people will say, this happened, it disrupted my sleep and then that was it. So, the circadian system then that's, it's so useful to know about as a therapist, because you can think about then, what people can do to keep a stable, rhythm routine going. And that's a component of a number of the psychosocial therapies for bipolar work on routine stabilisation. And then the other big biobehavioural theory that's around in the literature is around dysregulation of the system that organises our pursuit of rewards. So the approach system and the idea that this system might be, almost have a bit of a sticky switch in bipolar. So in all of us, when we see something or we know about something we need to work towards, strive towards in the environment, our approach motivation would go up and then it would return back to where it was once we've finished that piece of goal striving. Theres an idea with bipolar, that maybe firstly the system's more sensitive. So it might go up easier and higher and then it might get a bit stuck, people might find they've achieved the goal but they still feel that heightened approach motivation, which then forms a bit of a platform for further goal striving because people might feel they want to do something with that energy and that motivation. And that's really helpful to be aware of as a therapist. I never think this is definitely going to apply to everyone, but it's something, it gives you some pointers of what to look out for. And some people I've worked with have just found it really helpful to think about it. Oh, it's not necessarily everything positive that might trigger off some of these feelings, it's particularly when I'm striving towards something, and I feel that energy and that kick. And then they might think about, well, I still want to do that in my life. How can I do that in a way that isn't going to end up in a hypomanic place. Rachel: It really makes me think about what you were saying, Tom, about this sort of interaction between these vulnerabilities and environment. And I'm thinking about you in a higher ed education institute where, it's institutionalised the sticky switch towards drive, isn't it? The more papers you publish, the more papers you need to publish, it must be hard for folk, as you describe, maybe with perfectionistic standards, maybe with kind of this reward striving and these underlying vulnerabilities, and then in an environment which really rewards that further. Tom: Yeah. And I, I think some research I'm doing here, we're trying to, I'm trying to look at how high standards and perfectionism kind of interacts with these positive life events. because it makes sense to me that if you have very high standards and drive when something, as always described to my client when something bad happens, it's, oh, I'm going to criticise myself and go into a depression cycle when I don't meet my own high standards. But when you do meet them, you don't put your feet up and rest. You go, right, I'm on a roll. What's next? So yeah, that is, I mean, I love academia. I'm definitely in the right place with my fellow psychology nerds. But it is hard at times because a lot of bipolar folk, and I'm one of them, can really hang a lot of self-esteem to goals, very goal focused. And when people are manic, it becomes really goal focused behaviour and wanting to achieve. So people with bipolar have very high sort of dysfunctional attitudes, beliefs about achievement, needing to be outstanding, perfectionist, et cetera. So a really important part for me, therapy over the years has been to try and, well, for me, like a lot of it is focusing on values and what matters to me and why I do this rather than just these kind of goals because it is you can't win in academia, can you? Because there's always another paper to write. There's always someone who's got a bigger H index than you. And so part of me is trying to just a little healthy dose of who cares. But also, just the work-life balance is really important for everyone and certainly that's the case with me. And living well with this is just really being able to just go, I've done a good enough job, I've done enough for today, I'm going to go home. That's really important because that, that drive to wanting to do more is very powerful in bipolar. Yeah, trying to be a little bit more sensible and boring is a good thing. Rachel: Well, well certainly in researching this podcast, I can see there's nothing boring or minimal about your research output and publications. Tom: I mean, boring in a, I mean this in a, I use the term strategic boredom with my patients. I mean, hopefully my work isn't boring- I find it exciting. But I mean, sometimes there's that urge to, to work more, to do a big idea, to go out and socialise that drives mania. And actually, strategic boredom is, I need to go home and just binge watch some Netflix. It really is, can be as simple as that. So that work-life balance is really key, but it's very hard, a lot of the time for people with bipolar because there's this real pull to achieve, I need to do more. What's next? Rachel: Okay. So to tap into your, both of your high achieving schema here, we've got challenge. You may or may not be aware of our Practice Matters podcast challenge, but as you'll know, we all love a good formulation of CBT and usually it has boxes and arrows, but this is an audio podcast. So here's the challenge. Can you give us a brief explanation about high bipolar disorder develops and is maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids? You can go individually, or you can help each other out, or you can fight it out up to you. Kim: So I'd say, you could take a diathesis-stress model, where people may have a preexisting vulnerability, and that can be in the form of a tendency to the high and low mood states, potentially with a genetic component, family history that's more or less maybe important for different people as well as that alongside them might, there may be, as Tom's alluded to, particular beliefs that interact with that tendency or ramp it up, whether those are about achievement or are about mood itself and the implications of the mood itself and what you have to do with it to, to manage it or get the most out of it. And then when the early signs of a mood swing emerged, either because of a trigger or just out of the blue, how we meet that swing can affect how it develops. People might have thoughts like, this is my chance to show everyone what I can do when they experience some increase in activation and mood. And then that can lead to goals striving behaviours that can drive mood up further, potentially via sleep restriction or just more excitement or use of stimulating substances. And then on the other side, daily signs of depression might be interpreted as, oh, I'm getting low, I can't inflict myself on the world. I have to retreat, withdraw. And then as we know, in terms of the behavioural theory of depression, that can make the depression worse, and then either the high or the low episode as we've already talked about can create further problems for the person, further stress, which then can feed into future triggers, but also can reinforce some of the beliefs people might have. Like mood is dangerous and uncontrollable. Or if I don't try a hundred percent on everything, then hings are going to catastrophically fail. So there can be that sort of cycle in that respect. Tom: Just to add to what Kim was saying there about how it can escalate from a trauma informed perspective, thinking about how trauma and these high standards interact. Let's imagine a diagram, longitudinal formulation, if your listeners can sketch it out in their heads. Early experiences, was a very high achiever at school, competitive athlete, and was very criticised when I didn't get top marks by my parents, I was someone who came from a background where there was a lot of pressure, they then developed beliefs that I need to be outstanding, I need to work really hard, I need to impress others. And then when they're starting to become manic, they're feeling very overwhelmed at work, they're feeling that they can't cope. They start to get these ideas and confidence, and then the way they make sense of it, the appraisals is, I can finally reach my potential. I can work really hard. I can get promoted. People will respect me. I can use this energy; I can use this confidence and mania. And then they go with it and they do all the things Kim was talking about that bring your kind of mood up, working more, sleeping less, taking drugs, et cetera, that maybe brings mood up more. So yeah, how people think about these when they're starting to become unwell really is important in whether it becomes a full-on relapse. Rachel: So there's these background vulnerability factors, which include all the biological, and pieces that we've spoken about already. But there's also these beliefs which may have been formed and influenced by this early experience of having achievement rewarded and beliefs that have been developed around that about the need to strive and achieve. Mood changes or starts to change, there's interpretations of that which then lead to these behaviours depending on which, direction your mood might be changing in, maybe withdrawal, maybe striving further. And that leads into, again, of other stressors, other challenges and can strengthen some of these earlier beliefs we have about mood, which kind of see us cycling around the bipolar cycle. Tom: And if people feel like they were very creative in a past manic episode, and we have to respect that actually, people think that they're very, you know, I'm really creative, et cetera and I get great ideas when I'm manic. There might be a bit of truth to that. There might be a bit of truth, certainly in early stage in hypomania, so we do need to listen to that. But the problem is, it can spiral out of control and what starts is maybe a sensible idea becomes very grandiose, very overly confident. Rachel: I think you passed the challenge. I'm not sure whether you cheated slightly Tom in asking people to imagine arrows. I think I think we may have strayed from the rules, but I'll give it to you because it was such a clear explanation. So given this understanding of the maintenance of bipolar disorder, what are the key elements of standard CBT interventions for bipolar? And I know there are many, and we'll talk about sort of the family of interventions as we, we move on, but what are the key elements that we might see in CBT for bipolar disorder and how they link to this development and maintenance of the problem? Kim: I suppose if you're thinking about relapse prevention work, then you're probably thinking about psychoeducation, about bipolar sort of looking at people's information needs in relation to bipolar, and around medication treatment. How the person, what their relationship is with medication, are they able to get the information, advice and support they need around that and with their prescriber? And then you're thinking about somebody's pattern of activities and their routine because you're thinking about this stabilisation idea with rhythms and routines and exploring that together. And if you are a kind of traditionally trained CBT therapist, then you've already got the skills for that in terms of activity monitoring and scheduling. So there'd be an element of that. You often would do a life chart with people to look at the patterns of relapse and what likely triggers might be, and also protective factors. And then there'd be a piece around looking at early warning signs of those episodes and how you might cope with those, what's worked, what hasn't worked, what you'd put in place and making a relapse prevention plan and thinking about how you would store it, revisit it, who you would share it with. And then I guess another particularly cognitive piece in it might be around, not only the cognitions that come up when somebody's starting to get unwell and how you might work with those, but also there could be longstanding kind of cognitive patterns that increase vulnerability, as Tom's alluded to, if people have certain beliefs about, ongoing beliefs about, achievement, for example, or about what mood means and how dangerous it is. If those beliefs are there on an ongoing basis that might make people maybe more vulnerable to relapse. You'd look at factors in the person's life that could, that they could work on that would make them less likely to get unwell. That's in the kind of classic relapse prevention package, and I suppose for acute depression, you'd be very much doing in traditional CBT what's done for unipolar depression. So Beckian CBT for unipolar depression, but with some extra components, thinking about psychoeducation, about bipolar relationship to medication, bearing in mind this circadian rhythm potential idea. And then at the end of the, at the end of the course of therapy, thinking about doing some work around manic relapse as well as depressive relapse. Tom: And for the manic side there really is some quite simple behavioural stuff that can be done. So your listeners will probably know, as Kim said, about behavioural activation for depression increasing activity, but really some fairly simple stuff around decreasing stimulation and activity if people are starting to become manic is really important. This is what I was saying about the term strategic boredom, we're actually trying to just watch a work life balance, reduce excessive socialising and all of that, and working on that sleep pattern. Some quite simple stuff can really have a really big impact. Rachel: So it sounds on the surface of it, as you describe it, it's almost a bit like the kind of the standard protocols for depression. You might start working very much in the here and now, and then working backwards while solving those problems. Working backwards maybe to doing some more work on the longitudinal part of your formulation around these vulnerabilities and then thinking about relapse planning. But I guess from what you've already said that people present at very different times and stages, for therapy in this area. Is there a typical good course of therapy and if so, what does that look like? Kim: So I'm a big fan of thinking about starting where the person's at. I think if you have somebody who's well and seeking advice and support around relapse prevention, if you start off with a depression protocol, it's probably not going to feel particularly relevant. So you're thinking, what does a person need and then sequencing the bits depending on what's most important. So if I'm working with someone who relapses very frequently, even if they're well when we start, we probably need to front load thinking about responding to a relapse, because it may well happen in the next couple of months. Whereas if you're working with someone who very rarely relapses, we can probably do that later on if the person wants to focus on that. So there's that sort of element of planning and moving things around to suit the individual. Rachel: And Tom, I’m aware you were talking earlier about how sometimes the time to have therapy is when things are stable. That said, as a therapist I often find it's almost harder to work with people when they're well, because you don't have a kind of active symptom to get your teeth into for, that's a terrible expression I've just used, but I think you probably know what I mean, really seeing things in the here and now that you can be intervening with. Does that complicate delivering therapy? Tom: Yeah, I think that can be the case sometimes. There's a certain amount of distress you need to have the motivation to engage in therapy because therapy's hard work. I think it doesn't come up too much because a lot of the time people will be stable, but they might be recovering from an episode, they're worried about a future episode. And some of the works Kim's done is even when people are stable in moods, they might have be a bit depressed or a bit emotionally up and down. So there's still stuff to work with. Anxiety, for example, a lot of people with bipolar have problems with kind of various anxiety problems as well. For me, a good course of therapy is about doing this relapse prevention work, the psychoeducation, what I'd say the more here and now, kind of surface level, like what you're getting right now, your thoughts and your emotions right now. And, for me, a good course of therapy goes a little bit deeper and that's what I'm really interested in and that's where it can be useful, even when people are stable in mood, if we're going at that core belief rules for living level, those high standards, those dysfunctional attitudes, beliefs about achievement and trauma often as well, like early trauma, I think that's a really good course of therapy if it goes a little bit deeper. Rachel: So we've talked a bit about a standard CBT package if you like, and there's lots in there, which I think if people haven't been working with bipolar disorder, you can immediately see the transferable skills and knowledge that people have. But I know you've both been involved in developing and applying different approaches to treating bipolar disorder, including using dialectical behavioural therapy and behavioural activation approaches. And Tom, you're the editor of a very recently published Handbook of Psychological Therapies for Bipolar Disorder, which seems like a really comprehensive and brilliant resource. Can you tell us a little bit more about the diversity of treatments, and when and why we might look to different psychological approaches. Tom: Yeah, the book's out and it's a handbook, so it's trying to cover kind of everything and its 29 chapters I think. So it is pretty comprehensive. Rachel: My favourite chapter, by the way, or the favourite chapter title I've seen is one that you've written, Gently Bursting Bubbles and Raining on Parades: a chapter on problematic positive beliefs. Tom: Yeah. And according to my US colleagues, that's the most British chapter title they've ever had, apparently. But I really wanted to delve into that going deeper in the book. And it's called evidence-based and emerging because I've got chapters on the very strong evidence-base, like CBT and group psychoeducation but I wanted to give a platform to these kind of emerging therapies. Kim wrote a chapter about sort of behavioural, dialectical behavioural. We had a chapter about mindfulness, acceptance commitment therapy. But then there are also chapters on working with specific issues. So yeah, there's that book about positive beliefs about mania and challenging overly optimistic cognitions because that's a weird thing to do, because we're all used to challenging negative cognitions. But what about when someone's overly optimistic and you have to gently burst their bubble. It's a difficult thing to do as a therapist. So working with issues, so we did a working with anxiety, working with trauma and working in particular groups as well. So we had a chapter about how you might work with people who have a learning disability and bipolar disorder as well. So I wanted it to be comprehensive, for my sins. But it really to show that the relapse prevention work is key and it's really important, but there's a lot of work where you can go deeper and there's a lot of other work outside of relapse prevention work that is often needed if we're really going to give a comprehensive treatment to someone with bipolar. Kim: I think that's a really important message that just because somebody has a bipolar diagnosis, not to assume that what they're going to want to work on is something directly about the bipolar symptomatology. Some people may want to work on other aspects of life and living alongside bipolar. Some people might want to work on an anxiety disorder or PTSD or relationship issues and when it comes to the balance of new versus existing treatments, I think there's still quite a bit of work to be done, as we said, to get access to existing evidence-based psychosocial treatments, and potentially some tweaks to those and improvements to make them more effective or to make sure they're delivered better. And then the investment in new treatments might be around where we feel there are gaps or there seem to be gaps that aren't being addressed by the new treatments. So I think we need to be thinking about both. Rachel: What's your experience been like, Kim, of integrating some of those, for example, the DBT ideas or thinking about behavioural activation rather than a kind of full CBT type package? Kim: So the work I've been doing has been for people with ongoing mood instability or residual symptoms in between episodes, and it came out of a feeling that, certainly as a clinician, using kind of standard CBT packages with people where their mood is up and down an awful lot, felt a little bit clunky, because it felt like there were chunks of work we had to do and if somebody came in a different mood state, it was maybe it was the way I was applying it, but it was like, oh no, we're going to have to put that on pause while we do this. And I guess I wanted something that was more like a set of principles that you could use whatever mood state somebody was in when they came to the session. And the work I'm doing at the moment is about integrating sort of behavioural activation with some emotion regulation concepts and techniques, primarily from dialectical behaviour therapy. So it's behavioural activation, but with more focus than usual on the person's relationship to affect and how they might think about their feelings or emotions or affect and how they might respond to it. Because finding, and there is evidence about this in literature, just in terms of people's relationship to their affect, people who've had like lots of extreme mood states can sometimes feel quite burned by that and quite scared of their increases in changes in mood and energy and maybe need to befriend it again and work out which of the feelings states I can trust in terms of my feelings and what I might need to take action with so that maybe people are not always catastrophising or avoiding changes in affect. And that, that has been really interesting work to do but what I found, as I've talked to clinicians about is people are doing this already. So I feel like what I'm doing is simply formal formalising what a lot of clinicians around the country and around the world are doing anyway in terms of integrating emotion regulation techniques into their cognitive or behavioural practice. Rachel: And it sounds like importantly, really articulating those principles that you're coming back to. I know you work closely at Exeter with Barney Dunn, who's recently recorded a podcast with us thinking about ADEPT and working with positive affect and think targeting anhedonia. You know very much I'm hearing this theme come back through with all this depression work of coming back to principles and sessions because what can pop up in any session, even with unipolar depression can be so variable, can't it? Kim: Yeah absolutely. I think when people have got major sources of instability in their lives, whether that's life events or relapsing, unpredictable physical health considerations or whether that's mood state being very back and forth. I sometimes, when I'm doing training with therapists, use the metaphor of a tent in the wind. You're trying to peg a tent out before it gets really windy, you don't want to spend ages on one peg. You want to get a couple of key pegs in so when the wind hits, you've got something to fall back on that's keeping things in place. So usually if I've got somebody whose mood is really up and down, usually what we'll try to do at the beginning is get a few key things in place so then we've got something to refer back to when they come back in and they're feeling differently than how they did before, or they're experiencing a real exacerbation of how they're feeling. And a practical example of that would be relapse prevention early warning sign work, when you do that in therapy it can take sessions and sessions. I think it can be really helpful to do a quick version of that right at the beginning so that when somebody comes in and their mood's suddenly going up, you can refer back to that and it took you 15 minutes in the session and you can go over it in much more detail later on in the therapy, but at least you've got that peg in there to help you keep things in place. Rachel: That's such a helpful metaphor. And I think we're used to talking about therapists having tools in their tool belt. I love the idea of them having tent pegs that they can be working with their clients. So it sounds like there's a variety of approaches to treating bipolar disorder that, that, broadly fall under the CBT umbrella, like CBT/DBT/ACT, other related therapies but there are other therapies like family focused therapy, which we know are applied, and Tom you've talked about group approaches with different, maybe different modalities, but maybe some of those modalities, but applied in a different way. What do we know about the effectiveness and efficacy of these treatments? Tom: I think I briefly mentioned earlier, so the biggest meta-analysis that's been done to date shows that CBT group, psychoeducation, family focused therapy reduce the risk of relapse by about half nearly. And also they do appear to reduce kind of acute symptoms as well. Individual studies have also shown benefits, like it reduces how long the episodes go on for, it reduces the risk of hospitalisation, but I think the evidence is really strongest for that relapse prevention focus certainly. Rachel: And what does a good outcome for bipolar therapy look like? Tom: Well, it's based on goals. I think definitely, it’s based on what the patient goals was. As Kim said, sometimes people might not be particularly bothered in, you know, they might not want to work too much on relapse prevention, there might be other focus about their relationships or their anxieties, for example. I think for me personally, a revised relapse prevention plan is always a good outcome because people will usually have one, but a more CBT kind of informed one is good. But then I think something that goes deeper than, like I said before, that relapse prevention, something if people are able to reevaluate some of their high standards and soften those up a little bit, that's a really good outcome for me I think as a therapist, Rachel: So I guess all good CBT we're thinking about the individual's goals. Tom: We are, we're thinking about the individuals’ goals, we're thinking about the here and now, but we're thinking back to a bit of a deeper core belief level as well. You want to see some of those rules for living and core beliefs sort of soften up at the end of therapy, Rachel: Yeah, because this isn't a kind of one-off event that people are going to be experiencing. It's something that they need to be thinking about through their lifetime. Tom: Yeah, there's the having a really good relapse prevention plan and knowing what to do if you're starting to become unwell. But the deeper stuff as well, that reduces your future vulnerability. Rachel: And let's say you are sitting in front of a client with bipolar disorder for the first time. What can you reasonably say to that person about their outcomes? Because it’s one thing, thinking about the kind of these big trials, what do you say to someone presenting for treatment? Because the individual can benefit differently, can't they, depending on their own circumstances. What do we say to clients when they're presenting for therapy in terms of hope for outcomes? Kim: So I would be honest that we can't predict for a given individual exactly how the therapy will affect them or work for them. Generally, these therapies are found to be helpful. It depends on what the target is obviously, but for example, in reducing risk of relapse, I might have drawn a diagram of the person's mood switches, and it might be that, it nips the tops off or the bottoms off the highs and lows rather than you end up with a completely flat line. And I'll be curious about what the person's own aims would be around that and what would be tolerable for them. Because I think there can sometimes be a perception that people without bipolar have very stable mood and that's normal to have very flat, stable mood and that isn't the case. So just being interested in where people think is realistic to end up and where they would like to end up. But always keeping that space open for the possibility that the episodes may recur, symptoms might recur- but does that mean that you can't live well and live a valued life alongside that. Tom: Yeah, sometimes people will ask the question of can it be cured? And I think having just an open, honest conversation from a very recovery focused approach, is useful to say that it reduces the risk of relapse if you're depressed, it will hopefully help you get out that sooner. We're not saying it's going to stop it completely, just to sort of have these kind of smart goals and realistic expectations, but I think people take that on board if you say this can help,. It's like medication, it's not going to get rid of it, but it can help you live better with it. Rachel: And I've heard what you said about one of the myths about bipolar being that the manic or hypomanic episodes not necessarily being experienced as entirely positive and they can actually be quite negative for people, but for some folk, is there a sense that there might be losses involved in this if I'm going to nip the top off my curve? Tom: Yeah. It is hard. And again, that chapter you referenced, it's about there are positive beliefs about bipolar. I mean, not all, I say a minority of people, but there is evidence that some people with bipolar, they don't want to stop mania, in particular, or they don't want complete control over their moods. And that's often because they feel like they're more productive or they're more creative, for example. I remember once I was running a relapse prevention group that people had signed up for and 10 people who wants to stop getting depressed, all of them put up their hands. Who wants to stop getting manic? Like one person put up their hand? And this was a relapse prevention group. So this is part of the work. It is. And as we were talking about in that formulation diagram challenge, those beliefs that this is a positive thing and I can use this, that is often part of the process, and it spirals out of control. So sometimes having to work with these beliefs, which are often underlying by those kind of perfectionism and high standards is really important because there's no point doing relapse prevention work if the person isn't entirely convinced they need to stop getting manic. Rachel: And talking about efficacy and effectiveness. Do we know much about different groups engaging with this treatment? Are there diversity issues around who benefits? Who doesn't? Tom: I think we know in the UK certainly from one study that black service users were less likely to be offered CBT as I think I mentioned earlier, which, obviously it makes my blood boil. It isn't right. I don't think we really know about in terms of who kind of benefits the most really. I mean there was this one study that showed that the people who had positive beliefs about mania didn't benefit quite so much, as you'd probably expect. I don't think we know that. I think this is, this is one of the things that we're probably a little bit behind on is tailoring it a little bit more and seeing who benefits the most. I don't think we're there yet, to be honest. Rachel: So an area for more work and more research. And in your, you've both got extensive experience of developing interventions, teaching, supervising, applying the therapy. Where do therapists get stuck? What are the questions that they ask most frequently or the tricky issues that people come up with? Kim: So I think we've already mentioned about, that the issue of people may be having mixed feelings about letting go of high mood, and I think therapists do worry that it will come across like they're telling people not to be happy. So I think there's a couple of answers to this. I mean, firstly, not all positive mood is created equal, so I think it can be helpful to look at what different types of positive mood there are, and to work with people to discriminate between a kind of, okay, safe, high mood and one that is more indicative of the beginning of a relapse. And often people will say that the kind of more like contented happy feelings are not involved so much in a relapse, but the more energised, activated feelings are. But even within those, you wouldn't, I wouldn't want people to never, to be scared, to ever feel excited or energised. So what makes the difference? Because if we know what is particularly associated with those feelings heralding an episode, it means we can relax about the other times when we might feel excited and energised if it's unlikely they're going to lead to an episode. I guess the other thing is, it's not actually really the mood that tends to cause the problem. It's usually what people do when they're manic. That's the thing that people tend to say, they feel a lot of guilt or shame about that tends to cause lots of stresses in life, like overspending and so on. So for me, the target to address around a manic episode isn't really the high mood, it's the behaviour. And what I tend to work with people on is increasing a sense of control over the behaviour so that if there's a high, they do experience a high, it's not as damaging as it might be. Sometimes that does mean downregulating, the high mood because it helps the person to think straight about the next best thing to do. If you're really in the grip of a feeling, it can be difficult to make a wise behavioural choice. So sometimes there is that downregulation, but not always necessarily. And I think that can be quite, in terms of training therapists, can be a helpful message. No, don't worry, your main job isn't to make people less happy. It's to help people feel more in control. Rachel: That's really helpful because I imagine, as we've said earlier, that's quite, almost inhibiting for therapists thinking, my whole life I've been trying to make people feel better. I don’t want to take this away from them. So to focus, as you say, on the behaviour and the control rather than on taking someone's positive affect away from them. Tom: I think when I'm training therapists, one thing that people struggle with is to formulate the mania. They can bind into this idea that a lot of mental health professionals and people with bipolar do; that mania comes out of nowhere and it's very biological and there's kind of nothing you can do about it. When actually it can escalate quickly, but it often builds up for sort of several weeks and there will be early warning signs. So I always say to people, formulating the mania is key, and once you've got that, the rest will follow. I've said before about this issue of working with people when they're stable, when there are people, when the people, when they are unwell, it can be done. It just needs to be done in a particular way. Rachel: I know we spoke about high folk are often presenting for treatment, maybe not for the bipolar disorder, but sometimes for other comorbid issues that they're experiencing, so for example, presenting in services for treatment of an anxiety disorder or PTSD. And I think therapists can sometimes be nervous about treating those other presentations in that context if indeed they know about it. What do we know about the efficacy of standard evidence-based treatments for other presentations if they're the person's primary concern in the context of the bipolar disorder? Tom: Yeah, well, unfortunately there's not a whole lot of evidence. That's why kind of my book was, that came within the emerging part rather than the evidence-base. So we know, for example, about half a people who have anxiety with bipolar, would meet the criteria for an anxiety disorder at some point in their life as well. And there's quite high levels of kind of drug and alcohol abuse as well. There is evidence that CBT can reduce anxiety within bipolar disorder, but not a whole lot of research, PTSD as well. There's disproportionately high levels of traumatic events and PTSD and bipolar. And there’s a little bit of evidence, there's a couple of small RCTs about trauma focused CBT and about EMDR and how that can be used with bipolar. But, really not a whole lot to go off at the moment. But we know that in NHS Talking Therapies, that's usually what's worked with is the kind of anxiety or the PTSD, rather than the kind of bipolar per se. Rachel: So it sounds there's, as you say, it's emerging evidence, we don't know, but equally, it doesn't sound like there's a good rationale to withhold that treatment for folk. Importantly, we don't know that it doesn't work either. Tom: Yeah, there's, what is it? The absence of evidence or evidence of absence? I can't remember what the term is, but yeah, the stuff with trauma work and anxiety, for example, is pretty promising. Some people did prolonged exposure with bipolar and they found that it was fairly effective, nobody became unwell. There weren't any people who became manic as a result, for example. No, it's not a reason not to withhold it at all. It just needs to be done with kind of a few slight tweaks really, and just being cautious and for trauma work the stabilisation- I know there's disagreement about how much is needed, but for bipolar, even if it's just doing a simple relapse prevention work before you do trauma work can be really important as a bit of a safety net for you and your patient. Rachel: So we always like to take a moment in the podcast to think about self-care and self-reflection as working in mental health is so rewarding. I know we all love it, but it can also be very challenging on both a personal and professional level. If you really care about the people you're treating as hopefully most of us do, and bring not just your mind, but also your empathy, your whole self to the work- perhaps even more if you have lived experience of the challenges your clients are facing, as you've spoken about, Tom. How do you think therapists or as therapists, we might be challenged by working with bipolar disorder? What things might we have to examine, put under the microscope around our own assumptions, behaviours, how do we look after ourselves? Kim: I think one thing for me that I notice is, is that sense of, we usually work with people who don't like their condition. They don't like being really anxious. They don't like being really depressed and they want to change it. And this isn't, as we said, always the case for high moods. I think it's really important as a therapist to make sure that your agenda isn't at odds with that of your patients, not going in thinking, right, what they need to do is they need to work really hard on never becoming even slightly high ever again, when actually that's not the person's agenda at all. I mean, obviously sometimes we have to do, I have different, agendas for safety, but generally speaking, we want those to line up. Rachel: So it sounds in this work, it can really help actually think about when we're taking a stance towards therapy, that is what I'm doing to someone else rather than working with them and that kind of professional mindset is I know best for you, which I guess we don't want to have in place for any of the work we do, but it sounds like it really throws that into focus. Kim: Yes, exactly. It would be the case with anybody but, I think it's particularly at the forefront when you have somebody who may think, actually, I enjoy being high and it's not something I want to change. Tom: I think when someone is fully manic, like you'd see in Bipolar I, it can escalate quite quickly and it's very chaotic and scary and feels very out of control for the service user. And it's also the case for the therapist. It can be a scary time when people relapse like that. And it can be really emotional and sometimes clients can feel very anxious about the future. You will be as a therapist as well. So I think a lot of that when people are manic, it is difficult. And I think, just trying to remind yourself as your therapist, your own high standards, having smart goals, it's not a sign of therapy gone wrong or a failure from you or the patient's part if they do unwrap- that is the nature of the condition. And what we're hoping to do is that this is going to happen less often and you're going to be able to pick up the pieces quicker. Rachel: I suppose it's important. We can really believe that and model that in our own work. Kim: I agree so much with that, Tom. I think I've seen therapists feel like, oh, somebody's having a relapse or their mood's dipped, or it's gone up- I failed as a therapist. When actually this is, you are walking alongside them as they experience this. And it's an opportunity for you to learn more, for them to have an experience of the therapy during one of those phases and maybe learn how to relate to that episode and respond to it differently. It's a potentially a really helpful opportunity, even though you and the patient wouldn't have wanted that relapse to happen. So you know for therapists really not to catastrophise. Rachel: So in fact, it's not the work gone wrong. It is the work. Kim: It is the work, yeah. Tom: Yeah. Rachel: So one of the really great privileges of being a therapist is we get this window into the lives of others and, we get to benefit also from seeing their resilience and creativity and face of life's challenges. I wonder what you've learned from the people you've worked with and how this work may have made a difference, a personal difference even in your life, or the focus of your work. Tom: I mean, I'm always in awe of the bipolar community and their wisdom. I think the bipolar community is a, it is that it is a community, and you get lots of people supporting each other, which is a lovely thing. And when I ran groups in the NHS, I think, what was great is that we had the content, but we also learned from each other. And I learned from my service users and all sorts of wisdom, the kind of early warning signs you just wouldn't really be aware of. And the coping strategies, the people that have already be developed, people are amazingly resilient. And I think that term strategic boredom came from someone who sort of said, I need to be boring in order to stay well, which has stuck with me. I think another thing I've just learned is just not to underestimate how powerful, quite a simple intervention as a CBT therapist can be, work with people who have never had therapy despite living with bipolar for years or decades, and just a few sessions doing a relapse prevention work plan can be so helpful for them. So not to underestimate the power of something simple like that. Rachel: It may be a very simplistic parallel to draw and hopefully you'll correct me if so, but I'm struck when you're talking about that community and also earlier about, the perhaps the sense of ambivalence people might have around some of the work in terms of their goals. It reminded me a little bit of sort of the Alcoholics Anonymous movement, the idea that you're supported by people around you who will spot signs for relapse, who maybe have developed other strategies themselves to work with that. and benefit from that kind of wisdom when it's easy to see how the problem doesn't always feel like a problem. Tom: Yeah, I think peer support is really important and that's something that Bipolar UK is trying to roll out more is more peer support. Kim: Yeah, I think as therapists, we are, we're meant to be doing therapeutic interventions, but we don't have the monopoly on therapeutic interventions. So I really agree with Tom about the huge benefits that people can get from groups, communities around bipolar, but also I've done some work on lifestyle factors and bipolar and psychosis and hearing about the effects of nature exposure on people's wellbeing. There were so many therapeutic mechanisms in what people talked about with regard to time spent in nature. And it just helped remind me that formal psychological therapies are one small part of somebody's therapeutic journey and most of the therapeutic contacts actually really happen outside of the therapy room and we can help facilitate that and be open to that as therapists. Rachel: And as we've hinted at throughout this podcast, you're both really engaged in research and on the cutting edge of what's happening with bipolar disorder. What do you think are the really important questions that need answering or the next big challenges in the field? Kim: For me, it's that the main thing really in the UK is access  to evidence-based psychological therapies. I mean, that's around the world. In the UK we've got the benefit of a centralised, pretty centralised system. We've got quite a relatively high number of therapists trained in at least some of the approaches we need- but there are barriers around cost and resourcing that, so we might need to look at how we deliver the therapies to manage those issues, but also as I've said about the way that services are organised so that people don't find themselves in a different place in the system to where the therapy is available. I think that sort of systems-based research and development is really needed. Tom: Like I said, I think we're quite behind where CBT psychosis is. So I'd like to see us play catch up a little bit. I'm interested in the, this going deeper. There is a bit of evidence that dysfunctional attitudes can improve, following CBT and bipolar, but I think we need more research on that. Same with kind of trauma work and these high standards as goal focused behaviour. And yeah, there really hasn't been much about these positive beliefs and how that can impact treatment so I think we need to dig into that and try and work on some of these positive beliefs about mania as well. One thing that's really exciting is, I think the reason CBT for psychosis is there's better access and there's more research is because we have these early intervention in psychosis. It's not a guideline; it's a target to offer CBT and that's one thing the Bipolar UK report has called for is more of these targets and more bipolar specific care. One really important thing is, could we use this as early intervention? And there's a big trial up in Manchester led by Sophie Parker that myself and Kim are on the steering group for, which is essentially trying to do what those big trials for early intervention in psychosis did decades ago, years ago, for bipolar disorder. Can it actually prevent, can it actually improve outcomes for people who are at risk of bipolar disorder? And, that would be, yeah, that really would be a game changer if this shows some positive outcomes. So that's a definitely one to watch. Rachel: And we see again and again, don't we in mental health that you can have the best treatments in the world. And it sounds like there's still plenty to be developed around that, but actually if they're not implemented, and if there isn't the policy and the infrastructure around that to make sure that people access it, it’s not doing its job. And I know that whole, environment is maybe getting more complicated to access to, to influence. Maybe not with, we're recording this just a couple of weeks after the announcement about NHS England being folded up. So it'd be really interesting to, to see in this space what happens around those policy decisions and that implementation. But really great to know that there's folk like yourselves with such a deep and wide-ranging knowledge that hopefully will be influencing the next stages in that. If people want to learn more about your work, where can they access training or how can they get involved? Tom: So I am chairing special interest group for bipolar disorder. So if you log onto your system, if you want to sign up to that, you'd be very welcome. It's been recently restarted, having been dormant for a few years. My book's called The Handbook of Psychological Therapies for Bipolar Disorder and, Yeah, I'm on kind of social medias @drtomrichardson. I'll often share about my work there. Kim: And Tom and I are on the Psychological Interventions Task Force for the International Society for Bipolar Disorders. And we have in the task force, we have a working group at the moment who are putting together a web resource on evidence-based therapies for bipolar, trying to make it a one stop shop for clinicians internationally in terms of what should we be delivering, how should we deliver it, and links to useful resources. And we're hoping to launch that later this year. Rachel: That's fantastic. That's so useful for therapists to have a place that they can go to, that they can trust also. So that, that sounds brilliant. And the book Tom looks like an incredible achievement. I'm sure. people want to get their hands on that after listening to this, if their appetite has been wetted or I'm working in this area, or indeed, if they're already deeply burrowed in there. So in CBT, we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key messages or message would you like folk to leave with from this podcast regarding the work? Kim: So I suppose mine would be if you're a fully trained CBT therapist, you've got 95% of what you need to work with people with bipolar. And the additional 5% is important, but it's not complicated. Tom: I think A: it is possible to formulate mania and B: CBT techniques can reduce the risk of relapse, both for depression and mania. Rachel: So there's hope. Nice to leave on a message of hope. Fantastic. Thank you both so much. It's been brilliant talking to you. I think we could have done a series of podcasts on this. So thank you so much for your time and all your wisdom and all that you've shared with folk at home. Tom: You're welcome. Thanks for having us. Kim: Thank you. Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    
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  • Understanding and Treating Eating Disorders with Dr. Rebecca Murphy
    In this episode of Let's Talk About CBT: Practice Matters, Rachel Handley is joined by Dr. Rebecca Murphy, a clinical psychologist and researcher specialising in Cognitive Behavioural Therapy (CBT) for eating disorders. Together, they explore the complexities of eating disorders, effective treatment approaches, and ways to improve accessibility to evidence-based interventions. Resources & Further Learning: Visit cbte.co for information on CBT-E, training, and resources. Learn more about Rebecca’s research at the Centre for Research on Eating Disorders at Oxford (CREDO). The CREDO Contributors' Group is for individuals who are interested in our work, including people with lived experience of eating disorders, members of the public, and professionals with an interest.  People in our Contributors' Group may be invited to participate in future research and consultation if they wish.  Join our Contributors' Group by emailing [email protected]. Please contact: [email protected] if your clinical practice is interested in using Digital CBTe Rebecca’s research ad publications can be found here: https://www.psych.ox.ac.uk/team/rebecca-murphy Follow Rebecca on Twitter/X: @rebeccamurphyox for updates on her work. Read Overcoming Binge Eating by Christopher Fairburn – a key resource on CBT for eating disorders. Stay Connected: Follow us on Instagram: @BABCPpodcasts Send us your questions and suggestions: [email protected] Subscribe and leave a review – and don’t forget to share this episode with your colleagues! If you enjoyed this episode, check out our sister podcasts, Let’s Talk About CBT and Let’s Talk About CBT – Research Matters for more discussions on evidence-based therapy. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow   Transcript: Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode we talk to an expert in CBT who will share insights that will help you understand and apply CBT better to help your patients. Today, I'm really delighted to say we're joined by Dr. Rebecca Murphy, clinical psychologist and senior research clinician at the University of Oxford, specialising in CBT for eating disorders and its dissemination. Welcome, Becky. It's really lovely to have you on the podcast. Thanks so much for joining us. Rebecca: Thank you so much, Rachel. It's such a pleasure to be here, and to be part of this really interesting series that you've put together. Rachel: Becky, we go back a few years, right? We probably even unknowingly crossed paths in the psychology department when we were undergraduates overlapping. But ever since I've known you properly when we embarked on our clinical psychology training, you've been really interested and passionate about eating disorders. I'm wondering what got you interested enough in the field, personally, professionally to pursue this as essentially your life's work? Rebecca: Yeah, thank you so much, Rachel and it's lovely to be speaking with you, as we have known each other for such a long time. So, I guess my interest started with mental health generally, and probably I had an interest from a very early age compared to most people, because my father was actually director of a therapeutic residential community for people with severe and enduring mental health difficulties. And as a director, he actually had to live on site, so I actually grew up surrounded by people with various mental health problems, seeing the impact it had on people's lives and being able to observe the difference that support and care made. I carried this through and that's why I studied psychology as an undergraduate. And within my course, we looked at different areas of mental health and I was very interested in eating disorders and what I especially loved was their complexity and the multifactorial elements. So as with many other areas, they're sort of no single cause. Yeah, you're thinking about biological, psychological, social factors. But I think with eating disorders, it's a really nice example of how all of those elements come together. So that was kind of my early interest. And I wanted to do something that would really make a difference, and I felt as if eating disorders as a field is actually still relatively young compared to some other psychological disorders so I really thought, Oh, I've got an opportunity potentially to make a big difference, as a researcher and clinician, in terms of thinking about new approaches, new ways of understanding eating disorders. And when I started to work with people, I also loved seeing how much people could change. So I really felt that it was an area in which there's so much hope because most people do get better and that was really rewarding to be part of. So yeah. That's where it all started. Rachel: And do you think that desire to make a difference, and that sense of hope was rooted in those early experiences that you had of living in that community? Did you see people's lives change, impacted there? Rebecca: Yeah, I think I did. I suppose I saw two things. One, if it's part of your everyday environment, it's very de-stigmatising, so you just see how normal it is for all of us at some point in our lives to have various difficulties, and I think I didn't really see it as something separate or that it was something that made people fundamentally different. I just saw it as part of a sort of continuum, that maybe we're all on. And I did, I saw people change. I mean, not necessarily the parts of them which they appreciated and valued but I could see that when people were really suffering, that was something that if you provided people with care and support, they were able to come out of and then they were able to make changes in their lives in terms of what they wanted, in terms of living independently or no longer being in such a state of distress. Rachel: So you could say that mental health has been part of your experience in terms of your genetics, your social environment and your psychological interest yourself throughout your life then. Rebecca: Definitely. So for me it was an everyday conversation from a really young age. Rachel: And I know you're interested not only in the what or process of treatment for eating disorders, but you're also interested in how we deliver therapy to make treatment more accessible and widely available. And we'll get into some of the great work you've been doing in that area. But given this is a young field as you've alluded to and there's probably still a lot of work to be done, how easy is it for folk who need access to good evidence-based treatment for eating disorders to access that? Rebecca: It is such an important question and unfortunately there is, as is the case in other fields as well, but there's a huge treatment gap between the number of people who could really benefit from treatment and the number of people who actually receive it. And perhaps there are two, two major sources of this treatment gap. One is that often people with eating disorders, they feel a sense of stigma or shame surrounding the problem so people may delay seeking help or never seek help because they don't feel able to disclose it to someone and so that's sort of an internal barrier. And then externally other barriers include that there is really only a limited number of trained therapists to be able to help people with eating disorders. So even when people do come forward and seek help, there aren't enough specialists to meet demand. And I mean, that's true even in kind of wealthy developed countries, and we know that only a small percentage of people with eating disorders receive recommended treatments. Rachel: So it's that double whammy of actually, it's really hard to get yourself to therapy because of that stigma, because of those barriers, and then you get there and you might not even be able to access it, so a lot of work to be done there. Rebecca: Yeah, absolutely. So it's a really difficult journey for people. Another barrier is often that people might present for help, but due to a lack of training, quite often primary care staff, so people sort of GPs and other individuals at the first point of contact, they aren't trained well enough to easily be able to recognise eating disorders as well. So people can get missed, misdirected or dismissed and if they even make it through that barrier, they might have to wait years to get treatment if they're even offered any, many eating disorder services are so limited that they can only offer treatment to people that are considered to be at very high risk, so other people just get turned away. Rachel: And the term eating disorders covers a really wide range of clinical presentations. I wonder if you can tell us a little bit about maybe some of the unifying characteristics of eating disorders and also aspects that might differ diagnostically, and what we know about typical presentations our listeners might see day to day in clinical practice. Rebecca: Yeah, that's a great topic to consider and I really liked how you started with asking about unifying factors because it's something that our research group at the Centre for Research on Eating Disorders at Oxford, our position is that we're more interested in features or characteristics of eating disorders rather than diagnoses. And quite often you do have these shared or unifying characteristics, which are quite specific to the eating disorders, but are shared across the group. And one of those characteristics is what we call an over evaluation of shape and weight and eating, which is where people's sense of self-worth depends largely or exclusively on their ability to feel like they're doing well in the areas of eating, weight and shape. So often people might be feeling bad about themselves as a person because they feel that they're not able to do well in those areas, which are very much informing their sort of sense of self-worth. So this is quite a unifying characteristic across most eating disorders, but not at all. And quite often this characteristic drives other features of eating disorders that we see. So for example, if you are feeling that in order to be worthwhile as a person that, in terms of the areas of, for example, weight and shape, it quite often means that people end up developing strict rules about their eating. So this is where perhaps they have certain foods, which they do not allow themselves, they may set calorie limits. And these rules need to be followed, because they are rules, and that leads people sometimes to go on to actually eat a restricted amount of food which may mean that they develop being a lower weight or in some cases what can happen as well is because the rules are so strict, it actually causes them to have episodes of binge eating, where they lose control and eat an unusually large amount of food. And that's through a couple of mechanisms, including feeling as if they’ve broken the rules because often these rules are so difficult and demanding that it's almost inevitable they get slightly broken and that can trigger a “well, I've sort of messed up a bit, I might as well give in completely”. And also people get very hungry and in a state of psychological deprivation. So they're sort of craving and drawn to the very foods that they've banned themselves from having and people often feel incredibly distressed and guilty, as a result, and this reinforces their desire to want to diet more and be more concerned about their shape and weight, and they get stuck in that cycle. And so that's kind of one element and then we also have another sort of feature around eating disorders is that people are using eating in some way to try to cope with difficult or intense mood states or problems in their life as well. So that's another kind of characteristic feature amongst eating disorders. Rachel: And, in terms of the kind of labels we might put on these kind of presentations diagnostically, and I hear what you're saying, kind of there are these trans diagnostic features, these unifying features, what are the kind of presentations people might hear about, see, be intervening with in clinical practice? Rebecca: So probably the three most well-known eating disorders are Anorexia Nervosa, where people restrict their eating and become a low weight. Bulimia Nervosa, where people also judge their self-worth in terms of wanting to control eating shape and weight, and they will also diet, but at the same time they have episodes of binge eating and they may make themselves sick as well. And then there is Binge Eating Disorder which is where people have regular episodes of binge eating, feel very distressed about that, but they don't engage in the set of compensatory behaviours we see in bulimia nervosa, and the compensatory behaviours are fasting or making themselves sick those sorts of things. So they're the three most well-known. But then there's a group of what we might call other or atypical, which are still above the clinical threshold, but they don't quite meet the exact set of criteria of the other disorders. Rachel: So they're still distressing, they're still interfering with people's lives, and they're focused on these kinds of behaviours, but maybe don't quite fit the mould. Rebecca: Yeah, absolutely. Rachel: And what do we know about how significant a problem these eating disorders are population wide? Rebecca: Yeah. so actually eating disorders are, as well as sort of being severe, they are relatively common as well. There was a systematic review in 2019, which estimated that over 100 million people worldwide are currently experiencing an eating disorder. And in terms of kind of population estimates or how often over the course of somebody's lifetime they might experience an eating disorder, the most common eating disorder is binge eating disorder. So that affects around sort of 2-5% of the population of people over their lifetime, many cases go undiagnosed. Bulimia nervosa has a lifetime prevalence of around 1-2%. And the rarest eating disorder is anorexia nervosa, even though it's often the most well-known and the most perhaps visible on the surface level and that affects around half to sort of 1 percent of the population. And that's in terms of eating disorders above a clinical threshold whereas we also know that many people have disordered eating or eating problems below that threshold as well. Rachel: And I imagine there's a bit of overlap and people move from maybe one presentation to another over the course of their lifetime or the period of their eating related problems. Rebecca: Absolutely, yes and that diagnostic migration, where people may perhaps begin their eating disorder journey, meeting the criteria for anorexia nervosa, which could evolve over time. And another time that you see that person, they might be experiencing criteria, which is consistent with bulimia nervosa. That diagnostic migration is common and that's one of the reasons that our research group take a more transdiagnostic approach to understanding and treating eating disorders, because it doesn't really make sense to us if we were to see someone one week and it looks like they meet the threshold for one disorder and we seen them a week later, they meet the threshold for another disorder, to suddenly change our treatment approach based on that kind of fluid progression. It makes more sense, in our view, to take a trans diagnostic approach where we're really interested in what are those kind of unifying features which tend to be quite specific to eating disorders and we match and map our treatment onto those features rather than a diagnosis. Rachel: And potentially much more meaningful and helpful to those individuals as well. We're coming up to Eating Disorders Week in the UK towards the end of February and I've seen statistics on the BEAT website where they talk about the theme of the week is anyone can be affected by an eating disorder, and really those statistics do speak to that. And they talk about 1 in 50 perhaps in the UK experiencing these kind of presentations at some point in their life, which is really, it's huge isn't it, and speaks to the importance of the work you're doing. And in our culture, in Western culture, there is such a strong emphasis on the importance of weight and shape. It is actually hard to fathom sometimes why any of our young people grow up with a healthy, happy body image. We were just catching up on our kids, before we started recording and talking about my youngest, my seven-year-old daughter. And I was really shocked in this last week when she suddenly announced that she was fat and had a fat tummy. I'm really taken about where that come from, as it didn't come from chatter or talk around the house. And you hear these narratives so quickly in young people's lives. But obviously there's something about the kind of presentations you've been talking about, that some folk go on to really get trapped into this very single minded focus on weight and shape. Given the range of presentations, you've talked about these fluid presentations, the overlapping presentations, is it possible to identify a typical pathway into eating disorders? How does someone go from a feeling that they've got a fat tummy to this kind of overvalued sense of identity in their weight and shape? Rebecca: Yeah, that's a good question and I appreciated your lead up to that in terms of thinking about, how common it is and how worrying it is as parents and members of society to see our young people just start to exhibit essentially eating disordered type behaviours and thoughts, from such an early age, even if they don't meet the sort of diagnostic threshold. And actually studies have found that it could be sort of around one in five children and adolescents worldwide do exhibit these sorts of eating behaviours, which is really very common. In terms of the sort of pathway I guess every individual's journey is different, but there will be contributing factors. So there are certain risk factors that make some people more vulnerable to developing eating disorders, and essentially one of the biggest risk factors for eating disorders is something which many people engage in which is dieting. And for some people they can navigate that, they can sort of diet in a way that it doesn't dominate and take over their lives. But for some people, what starts as perhaps less sort of harmful dieting can really develop into something where people start to feel that the eating disorder is controlling them rather than the other way around. And sometimes you get a perfect storm of factors, so it might be, for example, I mean it's different for everyone, that somebody starts dieting, maybe they feel that generally other elements of their life are not in their control, so they get quite a sense of control because they're eating and perhaps early on is something they feel that they can control and change. Maybe they have an influence on the number on the scales, maybe they've had times in their life when they've been bullied or treated in a way or exposed to some kind of trauma which makes them feel bad about themselves, which makes them feel bad about their body. Maybe they get some positive feedback, sadly, from people on sort of you know, dieting or losing weight because of the weight stigma and our culture which values restriction. And maybe they then also have some difficulties in their life, which they then turn to controlling eating disorders to cope with. The sort of dieting pathway is quite a common pathway and perfect storms are created by maybe having some other things in the background, perhaps some triggering factors, perhaps there's a relationship breakup, loss of a job, some kind of trigger which presses people's buttons in terms of feeling bad about themselves and feeling like their life's out of control. And for other people, it could look quite different. They could be younger or older. I mean eating disorders could happen at any age. They could be older, they could be middle aged, and they could be someone who has always perhaps turned to food when they felt low, or as a way to deal with difficult feelings, but they start to do that more and more and maybe they sort of feel that they're trying to diet as well, that sort of out of control binge eating could happen. So yeah, there are lots of different ways into it. Rachel: I'm really struck by that as a getting older woman myself, that even in those environments where when you were younger, you might get positive feedback for losing weight, but also there might be some sense of, oh you don't need to diet or we shouldn't be dieting, whereas you get to sort of a certain age and it's completely normal to be on a diet or to be talking about time restricted eating or different types of whatever the latest fad is. I wonder, do you see interactions with other sort of fads and trends, like for example, we see the new sort of generation of weight loss drugs, like Ozempic, it’s all over the news and in celebrity chats. Do these things affect, interact with eating disorders in the presentations you see? Rebecca: Yeah, absolutely. So these kind of new weight loss drugs are having quite a major impact on eating disorders. Probably not clear exactly, how much at the moment, but I think they definitely are having an impact. These sort of types of drugs tend to work by reducing appetite, slowing down digestion, which essentially means people eat less and lose weight. But for people with eating disorders or a history of disordered eating, these medications can be potentially quite risky. If you think about the appetite suppression risk, so if people have reduced sense of hunger, it makes it easier for them to skip meals, easier to eat little and that can have quite negative consequences in terms of increasing people's risk of going down that pathway around strict dieting and not feeling that they can eat normally. And that can trigger binge eating cycles, especially when with quite often with these drugs, people are not able to take them for a sustained period of time, kind of forever, they're taking them for a period of time and then they're coming off them so that, can be really difficult in terms of triggering problems. Rachel: You've said about the importance of control often in these presentations, you get a sense of this is under control, I can do this, I can go further and then the drug goes. Rebecca: Exactly. And then there's a change in people's weight, which can be quite distressing for people. So I think it's very difficult. And I think the other way in which I see harm is because they turn the conversation essentially onto the topic of eating, weight and shape. And I mean the conversation in terms of what we talk about in our real life, what's spoken about on social media, the attention, the kind of space that is given to these topics, the amount of coverage of celebrities who've lost weight. We've got such a narrative now around what I think already was a really harmful idea, which is that this idea that anyone can just change their sort of body shape and size dramatically and that's kind of a really unhelpful fallacy. But sadly, I feel like these drugs are just reinforcing that. Rachel: Really unhelpful, isn't it? And I can imagine it's so much harder to convince someone that really the world isn't judging them on the basis of their weight and shape when that's so much of the narrative that's out there. And some of the best developed work in CBT for eating disorders that your group has done historically has been with bulimia nervosa. And that work, as you've alluded to, has been extended and enhanced to provide an understanding of the maintenance of and treatment of eating disorders across the board in this kind of overlapping picture we've been speaking about. Can you tell us a little bit more about this journey and our understanding? Rebecca: Our research group has been around for longer than I've been working in this role, and I want to acknowledge Christopher Fairburn and Zafra Cooper who played such a major role in really developing these psychological treatments. Originally, the treatment that we specialise in called Enhanced Cognitive Behaviour Therapy, or CBT-E, started life as CBT for bulimia nervosa back in, I think, sort of 1981 or something. And so that model was essentially a theoretical model and treatment approach for one eating disorder, bulimia nervosa, and the characteristics involved in that eating disorder. And that treatment was pretty effective, but I think it was probably around half of people who received it didn't get better and Chris Fairburn and Zafra Cooper, Roz Shafran and colleagues, what they did was took the approach of really trying to understand why it was that some people didn't get better. And, as a result of that investigation and exploration, they added more to that original model and expanded it. So one area that was very interesting is they found that for some of the people who didn't get better with that original version of the treatment, they actually had some difficulties almost sort of outside of the eating disorder, outside of that very kind of focused model and that included clinical perfectionism, core low self-esteem, we definitely see low self-esteem in people with eating disorders, but a really sort of deep seated core belief about feeling bad, interpersonal difficulties and essentially they expanded the model so as to allow for the inclusion of these broader, more external factors. So that was one way that they increased the potency of the treatment. They also expanded diagnostically outside of bulimia nervosa to take this transdiagnostic approach. So what they did was created a treatment that was suitable for people with all types of eating disorders, including anorexia nervosa, by adding in additional modules that were needed to be able to expand the treatment and create more of a sort of general trans diagnostic template understanding, that could then be applied to anyone with an eating disorder. And they also sort of really looked carefully at some other aspects which weren't originally considered in the treatment. And that included, for example, body shape checking which is something that often people who are very concerned about their shape and weight engage in behaviours to try and sort of check their weight, maybe looking in the mirror or pinching or feeling their bones. And actually, in the expanded version of the treatment, enhanced version, they included a therapeutic procedure dedicated to addressing shape checking, as it's quite a major maintaining mechanism or feature which tends to contribute to people's concerns that they have about their body. Rachel: So thinking then about the factors drawing together what we've been speaking about the development, the vulnerability, the risk factors, these factors that keep the disorders going. You may or may not know we have a challenge on this podcast. I know you do know that we love a good formulation in CBT, usually it has boxes and arrows and is drawn up in a whiteboard or similar or online. But this is an audio podcast. So here's our challenge. Can you give us a brief explanation about how eating disorders develop and are maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids. Is this possible, Becky? Are you up to the challenge? Rebecca: I will accept the challenge and I will hope that I can deliver. I would like to start by saying that the approach that we tend to take when we actually work with patients is that we don't use jargon, so we actually prefer to call the  formulation a diagram and we tend to always start drawing the diagram collaboratively with our patient by, first of all, beginning with what it is that someone most wants to change. So this means that everybody's diagram maybe starts in a different place and it would start with their own kind of words to describe it. But I can give you one kind of version. So, it's quite common that people say that they would like to perhaps change their binge eating, if they're binge eating but if someone isn't binge eating, they may often begin by saying they'd like to change how upset and distressed they are about their body, for example. So, if we imagined we started there and this is what we often consider quite a core factor, almost a driving factor behind many eating disorders is the way in which people judge their self-worth in terms of their ability to succeed in or control their eating, weight and shape. We could imagine that this begins at the start of the journey. So people are very concerned about their shape and weight and they really feel bad about themselves as a person if they're not controlling or doing well in those areas. And naturally leading on from this, you might see that this could lead to strict dieting; in order to control my shape and weight and eating, what I must do is follow this set of rules. And perhaps these are things that you've been told in the media that you shouldn't eat, or calorie limits you should stick to if you want to lose weight. And so people might start restricting their eating, that might get more extreme, which could mean that people develop being a low weight. And when people are a low weight that often comes with certain side effects, such as being preoccupied with food, feeling incredibly full from eating a small amount of food, losing interest in the outside world and quite often these side effects serve to really reinforce the concerns that someone has about their shape and weight and the need to diet. They think, well, I'm feeling full, I've only had a tiny amount I must've overdone it. Or I'm not really that interested in anything else in the world anymore, except what’s going through my mind about eating, shape and weight so that, that's what I'll focus on. So people can get stuck in a sort of vicious cycle there. And, or, if this might also happen, they might find that because they're really trying to control their eating and engage in this strict diet that they lose control of their eating and start to binge eat in the way that I described earlier, either through kind of hunger and cravings or through feeling like inevitably they break their rules, they feel they've failed, they give up control. And then when this happens, they think, wow, I need to really double down on my rules. I must be even stricter. Makes them even more concerned about the shape and weight and they get stuck in that cycle. And binge eating doesn't just come out of the blue, typically it happens in response to difficult or intense feelings that people have or things that happen in their life. And so there's a sort of another pressure, and that pressure can also put people under pressure to want to diet more in response to difficulties in their life. It could make people want to make themselves sick. Different eating behaviours can help to modulate or change people's mood. It can distract them, it can take their mind off things that they don't want to deal with in their life. But then of course those problems build up because people aren't dealing with them in their life. They're perhaps using these sort of unhelpful coping strategies, so you get another kind of vicious cycle there. So I hope that's illustrated some of what we believe is relevant to understanding eating disorders. Rachel: That was an excellent summary of lots of very complex processes there. And as you say, lots of different cycles going on. But with this kind of core idea, this over evaluation of weight and shape leading to these kind of behaviours around restriction and restraint, which then have this cascade of effects; the preoccupation with food, with how our weight and shape is doing, and the kind of narrowing of focus, which then, you know, kind of feeds back in or maybe we fail and we double down and maybe there's external pressures ramping up the pressure to control and creating further preoccupation with that and leading to other behaviours that might again be having sort of negative feedback into the loop. A lot of different directions I can see that people can go, but all cascading from this central preoccupation. And as we see across the disorders, I guess, these often self-defeating strategies to try and achieve those central goals. Rebecca: Yeah, absolutely. I mean, dieting is often seen, for example, as a solution to binge eating but in fact it's a major perpetuating factor. It's actually driving a lot of binge eating. Rachel: And given these factors that are, these drivers and these common factors that we're seeing, what are the key elements of enhanced CBT for eating disorders and how do they link to these maintenance factors? Rebecca: Yeah. So we could think of, and this isn't my analogy, I think this is an analogy of Chris Fairburn and his other colleagues, but eating disorders as being a bit like a house of cards. If you've ever sort of made one of those as a child, where you try to create this kind of structure with playing cards. And if you think of an eating disorder as a bit like that sort of structure, what you're trying to do in therapy and our sort of CBT-E therapy is you're trying to take out the key cards that are keeping the eating disorder in place. So you're mapping your treatment strategies and procedures onto exactly those maintaining mechanisms and you're trying to quite strategically pull those cards out. The first thing that you do in treatment, we call it starting well, which is stage one and essentially that's a bit like laying the foundation, I think, for a lot of the rest of treatment because you help people to have a better understanding of their own eating disorder, to become more aware of what they're doing in real time so that they can make changes. And you pull out quite a major card and that is, use an intervention which sounds simple but is quite complex in terms of the repercussions and what it changes in the structure and that's where you introduce regular eating. Quite often people come to treatment with large gaps as they're skipping meals or skipping snacks, or they might have quite chaotic eating habits or ways of eating. And they don't have a kind of structure of times when they eat and when they allow themselves to eat. So one of the sort of key elements that we put in place is trying to change that, and that seems to pull out some quite key cards in the eating disorder. So you're disrupting that long period of time people are going without eating, and essentially helping people to be able to eat which is the kind of major part. Rachel: You say Becky, that sounds simple, but I imagine I'm coming to treatment, I am literally petrified of what goes in my mouth and the impact it's going to have on my body. It doesn't sound at all simple. Rebecca: No, it's it sounds simple as a procedure if you sort of just say, oh, regular eating, it sounds like, what do you do in regular eating? You eat at regular intervals. But exactly as you say, it's certainly not simple for people to do. It's incredibly hard because eating is exactly the reason they've come to treatment because that's something that they find difficult. So it's not something thats easy to do. It's something that we have to help people to be able to build in that kind of structure and that has often has such a powerful effect in terms of, for example, often a rapid reduction in binge eating when people do that. It builds a foundation for people who are lower weight to then be able to add in more kind of energy into their diet. So that's kind of part of the starting process as well as people really understanding what's keeping their own eating problem going and becoming more aware of what they're doing. Quite often they might be on sort of eating disorder autopilot, just sort of going through the motions of restriction, dieting and so on but without really being aware of decisions that they might make or behaviours that they might engage in. So once we've started well, hopefully, we then move into the second stage which is where you kind of take stock and review progress. And you think, what have we learned about eating sort of so far together? What do we now need to do in the rest of our treatment to be really sure to treat together what it is that's keeping your particular eating problem going. So you plan on the basis of this sort of taking stock stage, and you plan stage three, which is where you really try and tackle the major elements that are keeping somebody's eating disorder in place. And that part of treatment is more kind of personalised, what you do and the order of what you do would depend on the person. Quite often you're addressing body image, dietary restraint, people's rules about their eating. You might be looking at how people cope with events and moods and helping people to problem solve or find other more helpful ways of coping with mood states. If somebody's a low weight, you would be helping people to make an informed decision to regain weight and then helping them with weight regain. So that's kind of Stage three. And then at the end, you want to help somebody to stay well in the long term. So you dedicate the final part of treatment towards really trying to empower people with what they would need to know in order to stay well in the long term. Rachel: So that's a brilliant summary of those four stages, an overview. Is it unfair to ask what a typical good course of therapy might look like? Typically, what do you do? And I'm thinking, you've spoken about getting people into regular eating. How do you persuade someone that's a good idea? And how do you address some of these other maintaining factors that we talked about? Rebecca: Yeah, establishing regular eating, what we're doing with people is helping to perhaps be able to take a step back from their eating disorder instead of perhaps kind of living it and being in it. It's being able to kind of step back and observe it from a distance. And that's why we do draw this diagram together because we want people to be able to kind of look at their eating problem and be curious and interested in it and try and understand some of the ways in which they're behaving and thinking about things which are keeping the eating problem going. And we also engender that curiosity and kind of distance perspective through helping people to self-monitor in real time. So that's where people write down in the moment, really anything to do with their eating problem and that might be a lot of things that actually are not eating- but that could be how people are feeling, what's happening in their life, what they're thinking about, which might be a consequence of what they're doing with their eating, or they might be things that trigger difficulties with their eating. And so when they've got that sort of curiosity and that stepped back perspective, it enables them to see with you, what sorts of patterns are actually holding them back and creating problems. And so at the same time as us suggesting that they experiment with doing things differently and eating in a kind of regular planned way, they're also recognising that the way that they've been doing it, which is often by skipping meals, maybe going the whole day and then perhaps losing control later or just feeling really tired and unable to concentrate and all those sorts things and kind of recognise that, that's not really helping them. And you're coming in and you're saying, I'll be here to support you but how about doing things differently, experimenting with doing things differently? And I'm going to give you some advice on something which really does help most people with eating disorders. Why not give it a go, see if life is any better doing it this way, at this point what have you got to lose? Now for some people, they feel like they've got a lot to lose and you do have to spend time in treatment really helping them to think about whether or not they want to get better and those sorts of things. But even with regular eating, people can choose what they want to eat. It's not about saying you have to eat certain things. It's about the timing. So they're starting off by perhaps spreading out, in some cases small amount of food, but it's actually giving them that structure, and you're kind of giving people permission to eat which can be really difficult for people.And we also at this stage would involve significant others. So really quite often recommend that people invite people close to them who have an influence on them and their lives into the end of one of our sessions. And so we can think about how other people can really support them and create the best environment that will help them to be able to make the changes that we're talking about in the therapy session. In terms of a typical stage one, it would look like quite often people making some changes like eating more regularly, binge eating would usually might go down, it's different for everyone, people starting to feel like they understand their eating disorder better. It’s not easy. I don't think with anyone, I wouldn't say it's kind of straightforward or easy and that's usually why, again, we see people twice a week in stage one, because they need that extra support to build therapeutic momentum, to not get stuck. And then, usually they have actually made some progress in stage one. There are still things that are difficult, but they can see a little bit that things can change. They're feeling a bit more hopeful but often even at that stage, there's still a lot of work to do. So we plan the rest of treatment, usually during that taking stock stage you kind of think, well, what's been difficult and everyone's different, it might be that they've had difficulties attending sessions because they have childcare issues or something external to them. Maybe they've had difficulty talking about things in the session because that's something that they find hard to do. Maybe you as a therapist think, Oh, actually, perhaps I've been doing things that haven't been that helpful. And so that taking stock stage is an opportunity for you both to put your heads together and think what do we need to work on? What might be getting in the way of change? What do we need to do for the rest of treatment? So usually that's a really important informative stage. So for most people that still coming to treatment, they're making changes. And then the third stage can look quite different for different people, but most typically we would start by thinking about how people judge their self-worth largely in terms of shape and weight. And there are different ways that we do that. I think of it a bit like, imagine that your sense of self-worth is shown in a pie chart and each slice in the pie chart is a reflection of an area of your life that informs your sense of self-worth. So for some people it might be work that dominates, if I give an interesting talk like this podcast, if people think this is a great podcast, maybe I feel good about myself, or if it goes terribly badly, I think maybe I feel awful about myself if that's a major area on my pie chart. Rachel: I'm sure you'll come away feeling good Becky Rebecca: If I don't really mind and I'm not too bothered, maybe that's because there are other areas in my pie chart, which help to balance things out, which I can think, oh, well this went badly but at least I'm still doing all right, with being, I don't know, being a wife or mother or engaging in my hobbies or something like that. But for people with eating disorders quite often, it's very much, that they've got all their eggs in one self-evaluative basket, like sort of weight or shape and when they feel like that's not going well, it’s really difficult. So we get people to try and bring in other slices to their pie chart, by engaging in areas of life outside of eating, weight and shape, maybe taking up hobbies they used to enjoy, maybe thinking about what other people they know do and really trying to build a life outside of eating, weight and shape. So it's a bit like, if you're a gardener and you put a plant in like mint and it starts to dominate and take over the garden, you've kind of got different strategies but one strategy is to surround it by other quite kind of vigorous plants which can help to squeeze it out. And that's what you're trying to do when you help people build up other areas of your life.   The other way to squeeze mint out is to sort of deprive it in terms of no longer feeding and watering it. And that's another approach we take, which is where we think, what is it that people are doing which is a natural consequence or expression of their concerns about shape and weight, but which are actually serving to keep them concerned about their shape and weight. And that might be frequently checking their body, scrutinizing themselves in the mirror, looking at parts of their body that they don't like, those sorts of things. How can we try and stop engaging in that behaviour? So sort of stop feeding and watering the over concerned slice so as to really shrink that slice of the pie char or limit the growth of that plant. So that's one approach we take with body image. And then there are the other areas, which, I've gone on now, so you might not want those, but we talked about dietary restraint, helping people regain weight, there's other elements of treatment. Hopefully, again, usually it sort of goes well to the extent that people find therapy helpful, they find change and benefits in those areas and then they stay on for the last part of treatment, which is how to stay well in the long term. And normally, at the end people maybe feel ready to end treatment. Which is great, or they feel a bit sad about ending treatment and that's okay too and we help them to feel confident about going forward and using what they've learned in therapy on their own Rachel: That's so helpful, and I love the, where you started, you talked about stepping back, you talked about the formulation with the diagram, you joined up, and it seems to me there's this kind of overall stance of almost like zooming out, stepping back from this very narrow focus of where my identity self-worth derives from, to just seeing that bigger picture, that bigger pie, that more variegated garden. I love the mint analogy, as someone who can grow very little, but has had limited success with mint as the only plant that actually does reproduce in my garden. I can see how one might overvalue one's identity as a good mint grower, but it seems that might lead to limited positives in one's life more generally, so this is a really helpful metaphor. And you talked about how people hopefully are getting benefit from this. What do we know about the effectiveness and efficacy of CBT- E? Is it effective? Is it equally effective for everyone? Rebecca: So I think, if we look at the research, when the CBT-E is well delivered by people who know how to deliver it, around half to two thirds of people who start, CBT-E experience significant improvement and though that sort of improvement is sustained, in the longer term, a year or so, later. So most people get better and it is one of the most well supported evidence-based treatments for eating disorders. However, having said that, that's still telling us that there are some people who don't get better, we have work to do. And we also know that eating disorders affects many different types of people. There is a stereotype that it's sort of young teenage girls, white, cisgender, there's this whole kind of stereotype. But of course they affect lots of people and so we probably do need to make sure that we do more work in making sure that we research how to deliver CBT-E in a way that benefits people, with the whole diversity of factors which exist in eating disorders. We might need to think about how best to adapt it and work with people who have eating disorders and other co-occurring conditions, and so on. But I guess the take home is that I guess, most people do get better but we still want to get more people better. Rachel: If you can get the right therapy from the right people, there's a good chance you're going to improve and get well. In recent years, you've been very much focused on that kind of accessibility to treatment. You've been focused on digitalisation of CBT-E. Given those issues you've talked about, the challenges that people face in accessing therapy that sounds really important. So what are you doing and how is it going? Rebecca: So the starting point here was that even though we have really good therapists delivered psychological treatments, only a small fraction of people receive them. And this is especially true for people with recurrent binge eating so because of the shame and sort of not being enough therapists. So what we've done is we've taken our therapist led CBT-E, and we've taken a printed program led version, and what I mean by this is a, sort of like a self-help book, Overcoming Binge Eating. It's the printed program led version of CBT-E, so you have a program delivering the therapy or the advice rather than a therapist but it's using the same kind of principles and ingredients from therapy. We've taken the printed program, we've taken our therapist led program and from that we've derived a digital app, a smartphone app and website-based program led treatment. So we've made some adaptations in terms of what we know about how people use digital treatments but we've used our tried and tested active ingredients to develop this treatment. We've involved people with lived experience, experts by experience. We've listened to them about what they found helpful, integrated their feedback and being through many cycles, iterative cycles, of development. So we do now have the treatment, it is available, but it's, even though it's on the app store, sadly you can't really do anything with it unless you are in the process of working with, for example, some NHS trusts that are using it now. But it's not available to everyone at the moment, but we are starting to run some pilots in the NHS and think about how to roll it out and implement it more widely. Rachel: Fantastic. So addressing those questions of whether it works and in whose hands it works. And across the sort of face to face and digital packages you've got right now, you've been teaching, supervising, applying that, developing it. I know that development of the digital space has been a labour of love for you. What are the most frequent issues that come up for therapists? Where do they get stuck? What kind of questions do they ask when using CBT-E? Rebecca: Probably the biggest struggle that people have is with how to apply CBT-E flexibly, but within a framework. And I think that's where quite a lot of the time therapists get stuck because, and this is partly our responsibility as trainers and supervisors to try and convey the message that the treatment itself isn't a set of, kind of, if/then rules; if the patient does this, then you must do this, because then in reality everyone's different. So nobody does exactly how you might describe in a training manual. So what we need to try and do is to do what I found very helpful in my training and supervision that I had from Chris and Zafra, which was think more about what are the principles underlying and guiding our decisions. So CBT-E is very much a formulation driven or diagram driven treatment. One principle is that you start with thinking really trying to understand something before you change it, trying to understand what's keeping it going, another principle is sort of doing a few things well, rather than many things badly, maybe staying focused as a therapist which people often find hard because typically, and this is only natural, when things get tough you tend to sort of drift away. You think, oh well, I don't know what to do about this within this framework, which perhaps you've internalised as a set of if/then rules. So you perhaps drift and bring in something else. I think that's probably the biggest area that we need to work on in terms of training and supervising, which is to help people to build in flexibility from the position of understanding a framework, but then still staying within an evidence-based approach rather than perhaps making up something new or trying to combine elements from a very different therapeutic model. Rachel: So we often talk in CBT, don't we about sort of fidelity with flexibility and of course when you're learning something new, it's terribly reassuring to have a series of tick boxes that you can tick off and procedures you can do. But if we're being truly formulation led and person centred in a way, thinking about the individual that's in front of us whilst adhering to that model and the evidence-based principles, we're not just ticking off boxes and doing the next thing or grabbing something that we think might work. And this area is one that can be personally taxing to work in. It can be challenging. I had the very great good fortune many years ago to work briefly with some of your more longstanding colleagues, Roz Shafron and Chris Fairburn. And I remember touching base with Roz after conducting a series of interviews with young women with anorexia nervosa for a study she was running. And being wonderfully empathic and thoughtful as she was, conscious of the impact it might have had on me sitting for the first time with a series of women who so undervalued their well-being that they were pursuing this path of self-starvation really. And so she asked me something along the lines of, do you feel ten years older? And in those moments, I think I did, actually. There was something so very sad and shocking about these amazing young women with so much potential and so many gifts and talents with so much to offer the world, working so hard just to take up less space in that world. And something else I noticed working with colleagues is how hard it is for those working in the field not to become very focused on food and weight and shape themselves in one way or another. I wonder what your reflections might be on looking after ourselves as therapists in this area and how we might be challenged by the work and how we might have to reflect on, modify our own assumptions and rules or how we look after ourselves generally. Rebecca: I quite like that expression of putting your own oxygen mask on first. And I think as therapists, we do have a responsibility to look after ourselves, not just because we've got a responsibility to ourselves, we are people too and we need to look after ourselves. But also if we aren't looking after ourselves then we risk not being the best therapist that we can be to help other people. So I think when I entered the field, I was mindful of the fact that, and this would be true for other areas as well, but you become vulnerable potentially to being kind of sensitised by or sensitive to the sort of topics of conversation that dominate your time with patients. And of course, one of the qualities of being a therapist is being empathetic and entering people's worlds. And sometimes you enter them so deeply that you kind of, you don't have that benefit of that distant kind of kind of perspective, which you really need in order to be helpful so it can be easy to get drawn in and then become almost enabling of the eating disorder because you're so on the patients side that they take you into their kind of world. I think as therapists, what we need to do is be reflective as we go on, that we’re not taking those perspectives and integrating them into our views. And, in supervision, I do raise this issue and I think it's important if people feel able to be able to talk to their supervisors about this, and to be reflective, so that we can be the best therapist that we can be, because I think people with eating disorders are understandably able to listen so carefully to what we say as therapists, they listen so carefully to anything we reveal in terms of our views of people's bodies, of how people eat and unless we are really unambiguous about, for example, valuing people of all shapes and sizes. And unless we're unambiguous about valuing flexibility and eating, then people will hear even the tiniest little bit of drift that you might take as a therapist towards internalising weight stigma or any of those sorts of things. I think we have a responsibility, not just in terms of looking after ourselves, but have a responsibility to our patients to be mindful about that. Rachel: And I guess the flip side of those challenges that we face and things that could be taxing are also the tremendous privilege that we have, having these windows into lives of people who are extraordinarily resilient, folk who really are surviving on so little, or cycling around these really self-defeating cycles of self-loathing. I'm wondering what you've learned from the people you've worked with, and how this works maybe made a personal difference in your life or the focus of your work. Rebecca: Yes, and I think that's absolutely true what you've said. I suppose when you start off training and entering this world, you can read in the literature about how effective treatments are and so on. But I think unless you actually see it for yourself it's quite hard to really believe the research. I mean, we know it's sort of there, but I think you need to see people being able to make changes, to really believe it to be true, which you then need to go on and be able to kind of inspire and encourage other people with their recovery. So I suppose that's one of the things that I think I have learned which is that, for many people, change is possible and I think that's something as a therapist that you need to see to believe. So I think that has been important to me. And I think the other thing that you see is you see, exactly as you said, amazing people with such skills and resources that perhaps they are very much putting into kind of perhaps the areas of weight, shape, and eating but what you're trying to do in therapy is encourage them to take a massive risk away from what feels safe and what feels, it might even feel the right thing to be doing, and you're trying to get them to step into a very unknown, scary world, trusting that things could be different, and I think maybe what I've learned from people is that taking those risks can be really worthwhile. And I don't think I'm a big risk taker myself, so I'd probably find that really quite hard to do so I'm quite impressed when people do that. I'm quite impressed by how many changes they make in their lives. But I don't think that's easy. It's quite inspiring for me. Rachel: And we've spoken about how the therapy is doing really well, half to two thirds of people seeing improvement getting better. The digitalisation, hopefully going to take it further in terms of access. What are the next big challenges, do you think? Can the therapy outcomes be improved further? What do we need to know more about? What don't we know and what are the big next steps to the field? Rebecca: Yeah.so I think, I mean, we're probably in the middle of this, but we spent a lot of time trying to develop really good evidence-based treatments and, naturally, we wanted to improve their potency or effectiveness. We wanted to take people from 60 percent of people getting better, we want to take it to 75 percent and so on. We spent a long time on that, which, is right. But at the same time, we didn't spend much time thinking about how do we actually disseminate these and scale them up to the many people who need it? How do we actually reach people other than the tip of the iceberg, which is what we see in clinics- we didn't really spend much time thinking about that. And we didn't spend a lot of time thinking about implementation. So again, when we carried out our research, which typically was pretty inclusive in terms of we had a lot of people with different co-occurring conditions, and all sorts of things, but there were certain things that we did in a research setting that were probably really important to the outcomes we achieved, such as, for example, in our treatment at the start, we see people twice a week. Now when our therapy from kind of research gets translated into everyday clinical practice, Rachel: That's not the normal model, is it? Rebecca: Its not! And they say, Oh, we can't do that in our service. We're only allowed to see people once a week, which is not a criticism of the individuals, but it's quite a problem when you can't translate it. And that wouldn't be acceptable in kind of drug treatments or heart conditions, Oh, well, sorry. Yes. Your heart medicine, we've changed it a little bit. Don't worry. We just took out one of the ingredients. You may get another one as a surprise. But somehow it’s considered to be acceptable to have a poor translation, and we also, as kind of researchers and clinicians leading these developments, we have a responsibility to try and think about that implementation, how is it going to be translated in everyday practice? How are we going to do that? What do we need to do? How do we talk to commissioners? How do we make sure that the implementation is achieved because otherwise we've spent so long developing these treatments but it's all a bit pointless if we don't reach anyone with them. If we don't implement them in the same way that we did them. So I think those are really important questions that we need to answer. I'm not saying we can't continue to do things that we've done before, try and understand why treatments work, identifying mechanisms of change and those sorts of things. But I do think we need to, yeah, really think about reach in terms of impact, we need to think about implementation as well. Rachel: So again, it's not just about what, it's about how we do this and the leadership and implementation of these brilliant treatments you've been developing. If people want to learn more about your work, where can they access training? How can they get involved? How can they become one of those therapists that's going to give this gold standard treatment in a way that people are really going to benefit from? Rebecca: Yes, we have a website, in collaboration with my colleague in Italy, Riccardo Della Grave. We've created a website called, which is cbte.co and that is full of information about CBT-E, including, training that we do and that training is free for some individuals such as NHS and certain organisations worldwide and you can find lots of information there. You can look me up in our research group if you put in psychiatry and CREDO, you'll find our research group which has some details. You can become a contributor, we have a group of people with lived experience and professionals and researchers who are interested in our research that we stay in touch with, so you can join our group. And I am currently on X as @rebeccamurphyox, and I need to explore other platforms because I know people have left to maybe abandon that platform. But if you follow me there, I'll then try and take you somewhere else when I find out where else I should be, maybe Bluesky and these other areas. Rachel: Fantastic. And we can put those various links in our show notes so people can follow those through and to any papers and books that Becky would recommend as well, we'll pop those in the show notes. So have a look there if you want to see where you can follow this up. Becky, in true CBT fashion, we like to summarise and think about what we're taking away from each session. I’m going to ask you to summarise and tell us what key message you would like to leave folk with regarding this really important work with folk with eating disorders. Rebecca: I think that change is possible, I suppose I think that is an important, area, and that in order to bring about change it's worth experimenting with doing things differently. And that's true for patients and therapists, so if you're somebody who hasn't yet experimented with delivering an evidence-based treatment like CBT-E, maybe now is a good opportunity to consider doing that. Rachel: Becky, you said early on in the podcast that you set out to make a difference in the world and I think from what you we've heard and what you've said and about the real change that has been facilitated for so many people, I think you can safely say that's what you're doing. So thank you for the work you're doing. I'm off to go and check on my garden, see how the mint's doing. Think about some strategies maybe to squeeze it out, maybe I'll just make myself a nice mint tea and have it with something that breaks the dietary rules. Rebecca: Brilliant. well, it's wonderful to have been here today and been given this opportunity. Lovely to chat with you as always, Rachel. And I appreciate people listening to this and I hope that what you said is true, that I have been able to help make a little bit of difference. So thank you so much. Rachel: Thanks so much, Becky. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team [email protected] That's [email protected] You can also follow us on Instagram @BABCPpodcasts. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that each new episode is automatically delivered to your library. And do please share the podcasts with your therapist, friends and colleagues. If you've enjoyed listening to this podcast, you may find our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Research Matters well worth a listen.    
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